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A nurse is calculating the total fluid intake for a patient over a 4-hour period.

The patient consumed 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.

How many mL of intake should the nurse record on the patient’s chart?

Answer and Explanation

The Correct Answer is ["1160"]

Step 1: Convert All Fluid Intake to Milliliters (mL)

To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:

1 cup of coffee = 240 mL
4 oz of orange juice = 118.3 mL
3 oz of water = 88.7 mL
1 cup of flavored gelatin = 236.6 mL
1 cup of tea = 240 mL
5 oz of broth = 147.9 mL
3 oz of water (another serving) = 88.7 mL

Step 2: Calculate Total Fluid Intake

Add all the converted fluid amounts together:

Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL

Step 3: Round to the Nearest Whole Number

Round the total to the nearest whole number:

Rounded total = 1,160 mL

The nurse should record 1,160 mL on the patient’s chart.

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Correct Answer is D

Explanation

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.

A. A patient’s address would be an example of personally identifiable information. B. HIPAA is a federal law, not a state law. C. HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form. D. Information about a client can be disclosed to family members at any time.

Correct Answer is D

Explanation

Choice A rationale

A patient’s address is indeed an example of personally identifiable information. This statement is correct and does not indicate a need for further teaching.

Choice B rationale

HIPAA is indeed a federal law, not a state law. This statement is correct and does not indicate a need for further teaching.

Choice C rationale

HIPAA did establish regulations of individually identifiable health information in verbal, electronic, or written form. This statement is correct and does not indicate a need for further teaching.

Choice D rationale

Information about a client cannot be disclosed to family members at any time without the client’s consent. This statement indicates a need for further teaching.

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A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is D

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