a nurse is calculating a clients intake and output during the last shift the client has had cup of gelatin a skinless chicken breast 1 cup of green b
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NCLEX-RN

NCLEX RN Exam Prep

1. A client's intake and output are being calculated by a nurse. During the last shift, the client consumed � cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?

Correct answer: A

Rationale: The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, � cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.

2. All of the following factors may contribute to client falls EXCEPT:

Correct answer: A

Rationale: Client falls can result from various factors, both intrinsic and extrinsic. Intrinsic factors include health conditions like urinary frequency, which increases the need for bathroom visits, decreased visual acuity, and confusion. These factors can directly contribute to an increased risk of falls. However, contact dermatitis does not directly lead to falls. Contact dermatitis is a skin condition caused by contact with irritants or allergens and does not inherently predispose individuals to falling. Therefore, among the given options, contact dermatitis is the only factor that is not directly associated with an increased risk of falls.

3. Mr. Thomas is a well-groomed 68-year-old male patient who had prostate surgery two days ago. He has an indwelling catheter and a urinary drainage bag. You have weighed him at 9 am each morning for 3 mornings in a row. Today, on the 4th day, his morning weight is 3 pounds more than it was the day before. Why could he have gained these 3 pounds in one day, on a 1000 calorie diet?

Correct answer: B

Rationale: The correct answer is that the weight gain may be due to the urinary drainage bag not being emptied today, while it was emptied on previous days. This scenario is common and can lead to an increase in weight that is not related to food intake. Choice A is incorrect because assuming visitors are sneaking junk food is speculative and not based on facts. Choice C is incorrect as there is no evidence to suggest the scale is broken. Choice D is incorrect because any unexplained weight gain should be investigated further, even if it seems insignificant at first.

4. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

Correct answer: B

Rationale: In a situation where a patient is in significant respiratory distress, bilaterally percussing the thorax to note any differences in percussion tones is a crucial nursing intervention. Percussion provides instant feedback regarding changes in underlying tissue density, which can give important clues about the patient's physical status. This hands-on assessment technique is readily available and can be performed promptly. Counting the patient's respirations, while important, may not provide as much detailed information as percussion. Ordering a chest x-ray and waiting for the results can cause a delay in assessing and addressing the patient's immediate needs. Inspecting the thorax for new masses and bleeding, although relevant, may not offer as much real-time information about the patient's condition compared to percussion.

5. Who is most likely to arrange the discharge of a patient to their own home, a nursing home, or an assisted living facility?

Correct answer: C

Rationale: Social workers play a crucial role in arranging patient discharges to suitable facilities. They collaborate with healthcare professionals to ensure that patients are transitioned to the most appropriate setting post-hospitalization. Social workers focus on the holistic needs of patients, including their social and emotional well-being, to facilitate a smooth continuum of care. Choices A, B, and D do not typically have the primary responsibility for arranging patient discharges to various facilities.

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