A nurse is calculating a client's fluid intake over the past 8 hr. The client had one 8-oz cup of coffee, 3 oz of juice, and 12 oz of soda. The client's water pitcher had 300 ml and 200 ml remains. The client also had IV fluids infusing as 40 mL/hr via an infusion pump. How many ml should the nurse document as the client's total Intake for the shift?

Answer and Explanation

The Correct Answer is ["1110"]

8-oz cup of coffee = 8 oz (since 1 fluid ounce is approximately 30 ml, this is roughly 240 ml).

3 oz of juice = 3 oz (approximately 90 ml).

12 oz of soda = 12 oz (approximately 360 ml).

Water pitcher had 300 ml, and 200 ml remains, so the client consumed 300 ml - 200 ml = 100 ml of water.

IV fluids infusing at 40 mL/hr for 8 hours = 40 ml/hr * 8 hr = 320 ml.

Now, sum up these values:

240 ml (coffee) + 90 ml (juice) + 360 ml (soda) + 100 ml (water) + 320 ml (IV fluids) = 1,110 ml
So, the nurse should document the client's total intake for the shift as 1,110 ml.

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Correct Answer is C

Explanation

A. Check the client for a positive Chvostek's sign.
Chvostek's sign is a clinical sign of hypocalcemia (low calcium levels), not related to the client's potassium levels. The given potassium level is low, not calcium.

B. Discontinue the TPN infusion.
While the potassium level is low, discontinuing TPN without addressing the potassium deficiency can lead to further complications. TPN can be adjusted to include potassium supplementation.

C. Request a potassium replacement.
The client's low potassium level (3.0 mEq/L) requires potassium replacement. This can be done through the TPN solution or via a separate IV infusion. This choice is correct.

D. Administer glucagon IM.
Glucagon is not used to treat low potassium levels.

A. "I will use caution when eating high fiber foods." B. "I will empty my pouch when it becomes one third full." C. "I will be certain to take enteric-coated medications." D. "I will change my entire pouch system at least weekly."

Correct Answer is C

Explanation

A. "I will use caution when eating high fiber foods."Clients with an ileostomy should be cautious with high-fiber foods as they can cause blockages.

B. "I will empty my pouch when it becomes one third full."
This statement is correct. Regularly emptying the pouch prevents it from becoming too heavy and ensures comfort for the client.

C. "I will be certain to take enteric-coated medications."This statement indicates a need for further teaching. Enteric-coated medications are designed to dissolve in the intestine, but with an ileostomy, the medication may pass through the digestive system too quickly to be absorbed effectively. Clients should be advised to consult their healthcare provider about medication forms, as liquid or non-enteric-coated medications may be more appropriate.

D. "I will change my entire pouch system at least weekly."
This statement is correct. Changing the pouch system regularly helps maintain hygiene and prevents skin irritation.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L. sodium 138 mEq/L, and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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