A client is admitted to the unit at 1500. The provider has prescribed a full liquid diet for the client. The client ingests the following from 1600 to 2115:

Chicken broth: 120 mL

Tea: 4 ounces

Ice cream: 1 cup

Soda: 6 ounce can

Water: 550 mL

Ice chips: 500 mL

The client voids the following:

At 1530: 400 mL

At 2015: 775 mL

At 2245: 200 mL

Calculate the cumulative fluid intake for the 3 p.m. to 11 p.m. shift. Note that intake and output is calculated at 2200 for the 3 p.m.-11 p.m. shift. (Round to the nearest whole number, use a preceding zero, do not use trailing zeros)

Answer and Explanation

The Correct Answer is ["1705"]

To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.

First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.

Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.

Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.

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Free Nursing Study Resources

Correct Answer is C

Explanation

C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.

A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.

B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.

D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.

A. Only punitive measures work B. Physician's order required C. All less restrictive approaches have been tried D. Inadequate staffing E. Remove restraints every 8 hours

Correct Answer is ["B","C","E"]

Explanation

B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.

C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.

E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.

A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.

D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.

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Naxlex Comprehensive Predictor Exams

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Correct Answer is C

Explanation

Medicare and The Joint Commission have identified which criteria that nurses must consider when using patient restraints? (SELECT ALL THAT PPLY)

Correct Answer is ["B","C","E"]

Explanation

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