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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.)

Answer and Explanation

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

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and the increase in heart rate from 88 to 100.

Itching: itching is an immediate symptom of type 1 hypersensitivity reaction that are common with blood transfusion.

A. The client leans on the crutches for support while standing still. B. The client advances the unaffected leg first while climbing stairs. C. The client stands 5 cm (2 in) from the front of a chair before sitting. D. The client bears weight on their axilla while standing in the tripod position.

Correct Answer is B

Explanation

A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

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1. IV fluids:

2. Juice:

3. Water:

Total intake:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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