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 A
Explanation
A: Having another nurse witness the wasted medication is the correct procedure. This ensures accountability and compliance with regulations regarding the handling and disposal of controlled substances.
B: Returning the wasted medication to the medication dispenser is not appropriate. Once a narcotic has been withdrawn, it cannot be returned to the dispenser due to contamination and safety protocols.
C: Placing the wasted portion of the medication in the sharps container is not correct. Narcotics should be disposed of according to specific protocols, which typically involve witnessing and documentation, not simply placing them in a sharps container.
D: Exiting the medication room to call the health care provider to request an order that matches the dosages is unnecessary. The nurse should follow the proper procedure for wasting the medication with a witness.
Correct Answer is B
Explanation
A: Auscultation, or listening for air injected into the tube, is not a reliable method for verifying feeding tube placement. It can lead to false positives and does not confirm the tube’s location accurately.
B: X-ray is the gold standard for verifying feeding tube placement. It provides a clear image of the tube’s position, ensuring it is correctly placed in the stomach or small intestine, reducing the risk of complications.
C: Aspiration of contents can help verify placement by checking the appearance and pH of the aspirate. However, it is not as definitive as an X-ray and can sometimes be inconclusive.
D: pH testing of aspirate can indicate whether the tube is in the stomach (acidic pH) or intestines (less acidic). While useful, it is not as reliable as an X-ray for confirming placement.
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