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.)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inflammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inflamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.
Let's now discuss why the other
Options are not the correct answers:
- Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood flow to the area, such as arterial insufficiency, rather than inflammation of the vein.
- Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood flow or decreased oxygenation to the area, which can be caused by factors other than inflammation of the vein.
- Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as fluid overload or localized inflammation, and its presence does not necessarily confirm the presence of phlebitis.
In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inflammation of the vein, which can be caused by various factors including irritation or infection. The other
Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with different underlying conditions or factors.
Correct Answer is B
Explanation
Cellulitis is a contraindication to receiving acupuncture treatment. Acupuncture involves the insertion of needles into the skin, and if the client has an active skin infection such as cellulitis, there is a risk of spreading the infection.
Option a is incorrect because hypertension is not a contraindication to receiving acupuncture.
Option c is incorrect because obesity is not a contraindication to receiving acupuncture.
Option d is incorrect because migraines are not a contraindication to receiving acupuncture; in fact, acupuncture may be used to treat migraines.
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