Fundamentals Question #13

Question

The nurse is reviewing a client’s intake and output. During the time period from 0700-1500 the client had the following intake and output: Two 16 oz bottles of water, one 8 oz. cup of coffee, 3 T. of antacid, three 6 oz. cups of ice. Calculate input in mL.

The family reports emptying the urinal measuring 8.5 oz., 18 oz., & 9 oz. The nurse emptied the bedside commode of 650 mL of diarrhea twice during the shift. The client has a chest tube that has 55 mL of drainage in the collection chamber. Calculated output in mL

Based on the calculation

Answers

  1. Fluid volume overload
    • Rationale:
  2. Dehydration
    • Rationale:
  3. Hypervolemia
    • Rationale:
  4. Fluid volume excess
    • Rationale:

Overview

Explanation

The correct answer is B The client is at risk for dehydration because more fluid is coming out than in is taken in. This client needs IV fluids and medication for diarrhea. The client is losing too much fluid and is not in overload. Hypervolemia is fluid volume overload and the client is experiencing a fluid volume deficit. The client is dehydrated and not in fluid volume excess.

The correct answer for Intake is = 1035 mL
2 bottles of water x 16 x 30 mL =480 mL
8 oz coffee x 30 mL = 240 mL
3 T of antacid = 3 x 15 mL = 45 mL
3 (6 oz cup of ice * this counts half) 3×6/2= 9 x 30 mL = 270 mL

The correct answer for Output is: 2420 mL
Urine output
8.5 x 30 mL= 255 mL
18 x 30 mL= 540 mL
9 oz x 30 mL= 270 mL
Stool
650 mL x 2 = 1300 mL
Chest tube
55 mL = 55 mL

Learning Outcomes

Test Taking Tip

Video Rationale