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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prior to percussing the abdomen
Bowel sounds are typically auscultated before performing any other abdominal assessments. This allows the nurse to get an accurate representation of the client's bowel activity without any interference from other assessment techniques.
B. Prior to inspecting the abdomen
Inspecting the abdomen involves observing for any visible abnormalities, such as distension or lesions. Bowel sounds are auscultated first to get an initial sense of the client's gastrointestinal activity.
C. After checking for kidney tenderness
Kidney tenderness assessment is not directly related to bowel sounds. These assessments are separate and do not impact each other's sequence.
D. After palpating the abdomen
Palpating the abdomen should be done after auscultation. Palpation can stimulate bowel activity, potentially altering the natural bowel sounds. Therefore, it is essential to auscultate the abdomen before palpating it.
Correct Answer is D
Explanation
A. Place the client in a supine position.
Placing the client in a high Fowler's position (sitting upright) is the appropriate position for inserting a nasogastric tube. This position helps facilitate the passage of the tube through the nasopharynx and into the esophagus and stomach.
B. Withdraw the tube if the client gags during insertion.
Gagging during insertion is a normal response. Advancing the tube slowly and having the client swallow can help pass the tube through the nasopharynx.
C. Measure the tube for insertion from the tip of the nose to the umbilicus.
The correct measurement for insertion is from the tip of the nose to the earlobe and then down to the xiphoid process (not the umbilicus).
D. Instruct the client to place his chin to his chest and swallow.
This instruction is appropriate. Asking the client to flex their head slightly forward and swallow helps guide the tube into the esophagus.
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