A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee. 4 oz of orange juice. 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea. 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client’s record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
The Correct Answer is ["1170"]
To calculate the total fluid intake for a client during a 4-hour period, the nurse should convert all the measurements to milliliters (mL) and add them together. One cup is equal to 240 mL, one ounce is equal to 30 mL, and one teaspoon is equal to 5 mL. Therefore, the client consumes:
- 1 cup of coffee = 240 mL
- 4 oz of orange juice = 120 mL
- 3 oz of water = 90 mL
- 1 cup of flavored gelatin = 240 mL
- 1 cup of tea = 240 mL
- 5 oz of broth = 150 mL
- 3 oz of water = 90 mL
The total fluid intake is:
240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The patient’s paralyzing agent dose is adequate, but needs to be given more often.
In a Train-of-four (TOF) assessment, four stimuli are delivered in rapid succession, and the response is observed. The number of twitches in the patient's thumb indicates the degree of neuromuscular blockade. In this case, if the patient's thumb twitches three times, it suggests that there is still some residual neuromuscular blockade, and the paralyzing agent dose is adequate. However, the frequency of administration may need to be increased to maintain the desired level of paralysis or neuromuscular blockade.
B. The patient’s paralyzing agent dose is too low and needs to be increased:
This would be indicated if there were fewer than three twitches in response to the TOF assessment.
C. The patient’s paralyzing agent dose is appropriate and does not need to be changed:
The response of three twitches suggests that there is still some neuromuscular blockade, so the dose or frequency may need adjustment.
D. The patient’s paralyzing agent dose is too high and needs to be reduced:
If there were no twitches or a complete absence of twitches, this might suggest an excessive dose. However, three twitches indicate some degree of neuromuscular blockade.
Correct Answer is B
Explanation
A. Integrity of the dressing:
Dressing integrity is important for wound care, but it is not the top priority when considering the client's immediate postoperative needs.
B. Need for suctioning
Maintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx removes the client's ability to breathe through the nose and mouth, so maintaining a clear airway is a top priority. Suctioning may be necessary to remove secretions and maintain airway patency.
C. Patency of the intravenous line:
Intravenous line patency is important for fluid and medication administration, but it is not the priority when compared to maintaining a clear airway.
D. Level of pain:
Pain management is important for the client's comfort, but it is not the immediate priority compared to ensuring a patent airway following a total laryngectomy.
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