A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water.
How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.)
The Correct Answer is ["1820"]
1. IV fluids:
- 150 mL/hr * 8 hr = 1200 mL
2. Juice:
- 4 oz * 30 mL/oz = 120 mL
3. Water:
- 0.5 L * 1000 mL/L = 500 mL
Total intake:
- 1200 mL + 120 mL + 500 mL = 1820 mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. The client has smooth, brown, irregular lesions on the back of each hand – These are likely seborrheic keratoses, which are benign, age-related lesions and do not usually require reporting unless changes suggest malignancy.
B. The client has glossy, white arches around the periphery of the corneas – This is commonly arcus senilis, a normal, benign finding in older adults that does not require intervention.
C. The client reports urinary incontinence – Urinary incontinence can be a sign of underlying issues such as a urinary tract infection or neurological disorder, necessitating further evaluation by the provider.
D. The client reports a decreased sense of taste – A reduced sense of taste is a typical age-related change and does not generally need to be reported unless it is sudden or associated with other symptoms.
Correct Answer is A
Explanation
A. Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B. Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C. Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D. Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.
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