A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?
The Correct Answer is ["1712.32"]
To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:
1,000 mL 0.9% sodium chloride IV (no conversion needed)
One 6-oz cup of coffee:
6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL
6 oz of water:
6 oz * 29.5735 = approximately 177.44 mL
One 180-mL bowl of soup (no conversion needed)
3 oz of flavored gelatin:
3 oz * 29.5735 = approximately 88.72 mL
3 oz of ice cream:
3 oz * 29.5735 = approximately 88.72 mL
Now, let's add up all the volumes:
1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL
Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sinus bradycardia: Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute. In this case, the heart rate is 64 beats per minute, which falls within the normal range, not consistent with sinus bradycardia.
B. Sinus arrhythmia: Sinus arrhythmia typically presents as a variation in the R-R interval with respiration, often seen as an irregularity in the heart rate. The provided characteristics describe a regular rhythm, so sinus arrhythmia is not the correct interpretation.
C. Sinus tachycardia: Sinus tachycardia is characterized by a regular rhythm with a heart rate greater than 100 beats per minute. The heart rate in this case is 64 beats per minute, which is not indicative of sinus tachycardia.
D. Normal sinus rhythm: Normal sinus rhythm refers to a regular rhythm with a heart rate between 60 and 100 beats per minute, P waves preceding each QRS complex, a normal PR interval (0.12 to 0.20 seconds), and normal QRS complex duration (less than 0.12 seconds). The provided characteristics, including regular P waves, regular QRS complexes, a PR interval of 0.16 seconds, and a heart rate of 64 beats per minute, align with a normal sinus rhythm interpretation.
Correct Answer is A
Explanation
A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.
B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.
C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.
D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.
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