A nurse is calculating the 8-hr fluid intake for a client who is receiving IV fluids and a clear liquid diet. The client had 880 mL of dextrose 5% in water IV bolus, a 6 oz cup of tea, 4 oz of apple juice, 8 oz of water, 3 oz of flavored gelatin, and 6 oz of broth.
What should the nurse document as the client's 8-hr fluid intake? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.)
The Correct Answer is ["1690"]
To calculate the 8-hr fluid intake, convert all the measurements to milliliters (mL).
1 oz = 30 mL, so 6 oz of tea = 180 mL, 4 oz of apple juice = 120 mL, 8 oz of water = 240 mL, 3 oz of flavored gelatin = 90 mL, and 6 oz of broth = 180 mL.
Add up all the fluid intake from IV fluids and clear liquids: 880 + 180 + 120 + 240 + 90 + 180 = 1690 mL.
Round the answer to the nearest whole number: 1690 mL.
The nurse should document 1690 mL as the client's 8-hr fluid intake.
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Explanation
A. Holding the dropper 1/2 inch (1 cm) above the ear canal during administration (option A) is indeed the correct action when administering otic medications. This distance helps to ensure that the medication is properly instilled into the ear canal without touching the dropper tip to the skin or ear canal, reducing the risk of contamination.
B. Placing a cotton ball into the inner ear canal is not necessary following otic administration. It may cause unnecessary discomfort to the client.
C. Straightening the ear canal by pulling the auricle down and back can make the medication trickle out of the ear. It should be held outward and upward.
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Correct Answer is D
Explanation
A) Placing one crutch on each side when assuming a sitting position is not indicative of safe crutch use as it does not provide adequate support or balance during the transition from standing to sitting.
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