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.)

Answer and Explanation

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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Correct Answer is A

Explanation

A. Giving oral care to a client who cannot take oral fluids is a task that can be safely delegated to an assistive personnel.
B. Checking intravenous insertion sites for signs of infiltration requires nursing judgment and assessment skills and should be performed by a licensed nurse.
C. Assessing a client's ability to ambulate involves clinical judgment and should be performed by a licensed nurse.
D. Demonstrating how to use a glucometer to a client with diabetes requires nursing knowledge and education skills and should be performed by a licensed nurse.

A. Purulent B. Serous C. Sanguineous D. Hyperemia

Correct Answer is C

Explanation

A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.

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Nursing Test Bank

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A nurse should assign which of the following tasks to an assistive personnel?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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