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","D","E"]

Explanation

C. Rapid heart rate (tachycardia) can be a sign of fluid overload, as the heart compensates for increased volume by beating faster to maintain cardiac output.

D. Shortness of breath (dyspnea) can indicate fluid overload, especially if it is new or worsening and associated with pulmonary congestion due to fluid accumulation.

E Elevated blood pressure can be a sign of fluid overload, as increased circulating volume can lead to hypertension.

A. This statement suggests a decrease in peripheral edema, which is a positive sign and does not typically indicate fluid overload. It may actually indicate improvement.

B. Dizziness can be a symptom of hypovolemia (low fluid volume) rather than fluid overload. It is not typically a specific sign of fluid overload.

A. Meeting the client's spiritual needs can help decrease suffering. B. Nurses are the only health professionals who provide this type of holistic care. C. Until spiritual needs are met, physical needs cannot be healed. D. It is important that the nurse's idea of spirituality matches the client's ideas.

Correct Answer is A

Explanation

A. Spiritual care is integral to holistic care. Addressing spiritual needs can provide comfort, meaning, and a sense of peace to clients, which can contribute to a reduction in suffering, both physical and emotional. Spiritual distress can exacerbate physical symptoms and affect overall well-being, so addressing these needs can lead to better outcomes.

B. While nurses play a significant role in providing holistic care, including spiritual care, they are not the sole providers. Spiritual care can be provided by chaplains, spiritual counselors, and other healthcare professionals trained in addressing spiritual needs. However, nurses often have frequent and intimate contact with patients, making them well-positioned to assess and address spiritual concerns and to collaborate with other members of the healthcare team to meet these needs.

C. While addressing spiritual needs can contribute to overall well-being and healing, physical healing does not solely depend on meeting spiritual needs. Physical healing involves medical interventions, treatments, and physiological processes. However, addressing spiritual needs can positively impact a client's emotional and psychological state, which can support the overall healing process.

D. Understanding and respecting the client's own beliefs, values, and preferences regarding spirituality is crucial. Each individual may have unique spiritual beliefs and practices that influence their health beliefs and behaviors. The nurse should approach spiritual care with cultural sensitivity and respect for diversity, ensuring that the care provided aligns with the client's beliefs and preferences.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)

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

Explanation

As a part of care planning, the nurse considers the client's spiritual needs. What is the Rationale for this concern?

Correct Answer is A

Explanation

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