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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Completing proper documentation of the medication error is important but should not be the first action. Immediate assessment of the patient is more critical.
B: Returning to the room to check and assess the patient is the first priority. The nurse needs to determine if the patient has experienced any adverse effects from the medication error and provide appropriate care.
C: Administering the antidote to the patient immediately is only necessary if the medication given has a known antidote and the patient is showing signs of adverse effects. Assessment should come first.
D: Alerting the charge nurse that a medication error has occurred is important for reporting and follow-up but should follow the immediate assessment and care of the patient.
Correct Answer is B
Explanation
A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.
B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.
C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.
D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.
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