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A nurse is completing an 8-hour I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client’s record?

Answer and Explanation

The Correct Answer is ["740"]

Step 1: Convert 4 oz juice to mL. 4 oz × 30 mL per oz = 120 mL

Step 2: Convert 6 oz hot tea to mL. 6 oz × 30 mL per oz = 180 mL

Step 3: Ice chips are recorded at half their volume. 100 mL ÷ 2 = 50 mL

Step 4: IV bolus is already in mL. 150 mL

Step 5: Convert 8 oz broth to mL. 8 oz × 30 mL per oz = 240 mL

Step 6: Add all the volumes together. 120 mL + 180 mL + 50 mL + 150 mL + 240 mL = 740 mL

The nurse should record 740 mL of intake on the client’s record.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

A. Reposition the client at least every 2 hours. B. Clean the wound with hydrogen peroxide solution. C. Massage reddened areas with dressing changes. D. Apply a heat lamp twice a day.

Correct Answer is A

Explanation

A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.

B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.

C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.

D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.

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A nurse is completing an 8-hour I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client’s record?

Nursing Test Bank

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