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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B. Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention.
C. Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate.
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Correct Answer is C
Explanation
A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.
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D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.
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