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 B

Explanation

A. Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B. Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C. Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D. Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

A. Provide the AP with a copy of the unit's policy. B. Notify the charge nurse about the incident. C. Talk with the AP about the technique used. D. Conduct an in-service on standard precautions.

Correct Answer is C

Explanation

A. Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B. Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C. Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D. Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Correct Answer is B

Explanation

A nurse observes an assistive personnel (AP) empty an indwelling urinary catheter drainage bag while not wearing gloves. Which of the following interventions should the nurse take first?

Correct Answer is C

Explanation

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