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?

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. This result indicates muscle injury but does not specify the source.

This statement is partly correct. An elevated troponin I level does indicate muscle injury, specifically damage to the heart muscle. However, troponin I is highly specific to cardiac muscle, so an elevated level would indeed specify the source as cardiac or myocardial injury.

B. Because the client has a history of unstable angina, this is a poor indicator of myocardial injury.

This statement is incorrect. A history of unstable angina does not diminish the significance of an elevated troponin I level. In fact, unstable angina is itself a serious condition that can lead to myocardial injury or heart attack, and an elevated troponin I level in this context indicates ongoing or recent myocardial damage.

C. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours.

This statement is not entirely accurate. While it is true that troponin I levels may continue to rise and peak within 12-24 hours after the onset of myocardial injury, an elevated troponin I level at any point is still a significant indicator of myocardial damage. It's essential to recognize elevated troponin I levels promptly to initiate appropriate interventions and monitor the client's cardiac status closely.

D. This is an accurate indicator of myocardial injury.

This statement is correct. An elevated troponin I level is a highly sensitive and specific marker of myocardial injury. It indicates damage to the heart muscle, which can occur due to conditions like unstable angina, heart attack (myocardial infarction), myocarditis, or other cardiac issues. Therefore, recognizing an elevated troponin I level in a client with unstable angina is crucial for proper management and further evaluation.

A. The test is noninvasive, and nothing will be inserted into the client's body. B. The client will remain on bed rest for 1 to 2 hours after the test. C. The client's pain will be managed aggressively during the procedure. D. The test will provide a detailed profile of the heart's electrical activity.

Correct Answer is A

Explanation

A. The test is noninvasive, and nothing will be inserted into the client's body: Transthoracic echocardiography (TTE) is a noninvasive procedure that uses ultrasound waves to create images of the heart. It involves placing a transducer on the chest wall to capture images of the heart's structure and function. The nurse should inform the client that no instruments or devices will be inserted into their body during the test.

B. The client will remain on bed rest for 1 to 2 hours after the test: This statement is not typically accurate for a TTE procedure. After a TTE, clients can usually resume their normal activities without any specific bed rest requirements, unless otherwise specified by the healthcare provider based on individual circumstances.

C. The client's pain will be managed aggressively during the procedure: TTE is generally a painless procedure that does not require aggressive pain management. The client may feel slight discomfort from the transducer's pressure on the chest, but it is typically well tolerated without the need for pain medication.

D. The test will provide a detailed profile of the heart's electrical activity: While echocardiography provides detailed images of the heart's structure and function, including information about blood flow and valve function, it does not directly assess the heart's electrical activity. For evaluating electrical activity, other tests such as electrocardiography (ECG or EKG) would be used.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding?

Correct Answer is D

Explanation

A client is scheduled for a transthoracic echocardiography (TTE). What should the nurse teach the client in anticipation of this diagnostic procedure?

Correct Answer is A

Explanation

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