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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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. The two-point gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg.
B. The four-point gait also requires weight-bearing on both legs and provides maximum stability, but it is not appropriate for a client who can bear weight on only one leg.
C. The swing-through gait is generally used by clients with paralysis of the legs or for those who need to use both legs minimally while moving with crutches. It is not the most suitable option for a client with weight-bearing restrictions on one leg.
D. The three-point gait is the correct technique for a client who can bear weight on only one leg. In this gait, both crutches and the affected leg are moved forward together, followed by the weight-bearing leg. This method allows the client to ambulate safely while maintaining the non-weight-bearing leg off the ground.
Correct Answer is C
Explanation
A. Choosing a vein that is soft on palpation may indicate it's not suitable for IV insertion. A vein with a slight bounce or resilience is preferable.
B. Selecting a vein in the client's dominant arm is not a primary consideration. Both arms are
usually suitable, and the choice depends on factors such as accessibility and patient preference.
C. Selecting a site distal to previous venipuncture attempts reduces the risk of complications such as infiltration or infection and allows for optimal vein preservation.
D. Choosing the most proximal vein in the extremity is not typically recommended for peripheral IV insertion. Veins more distal to the body are often preferred for initial attempts, with
consideration for vein integrity and accessibility.
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