A nurse is caring for a client who consumes 3 ounces of milk, 2 ounces of orange juice, 3 ounces of tea, and 4 ounces of water over a 4-hour period. The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Calculate the client’s intake for that 4-hr period in mL.

(Round the answer to the nearest whole number. Use a leading zero if it applies. DO not use a trailing zero.)

Answer and Explanation

The Correct Answer is ["480"]

480 mL.

The client's total oral intake over the 4-hour period is 3 ounces of milk + 2 ounces of orange juice + 3 ounces of tea + 4 ounces of water = 12 ounces. Since there are approximately 30 mL in 1 ounce, the client's oral intake in mL is 12 ounces * 30 mL/ounce = 360 mL.

The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Over a 4-hour period, the client will receive a total of 30 mL/hr * 4 hours = 120 mL from the IV infusion.

Therefore, the client's total intake for that 4-hour period is 360 mL (oral intake. + 120 mL (IV infusion) = 480 mL.

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Correct Answer is B

Explanation

The correct answer is that the nurse should expect to find reduced sweat production when performing a skin assessment on an older adult client. As we age, our skin gradually loses its ability to produce sweat and oil, which can result in dry skin¹.

Options a, c and d are not expected findings when performing a skin assessment on an older adult client. Increased skin elasticity, increased production of oils and thickened outer layer of skin are not typical age- related changes.

A. Ileostomy stoma is pink. B. Stoma draining moderate brown liquid stool. C. Client will not look at the stoma. D. Client states they are not interested in learning about stoma care E. Intake: 2,200 mL over the last 24 hr F. Skin surrounding the stoma is reddened and appears iritated G. Urine output: 650 mL over the last 24 hr

Correct Answer is ["F"]

Explanation

f) Skin surrounding the stoma is reddened and appears irritated.

The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.

Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Correct Answer is ["F"]

Explanation

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

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