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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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Correct Answer is C

Explanation

A: Identifying the type of sedative is important for treatment but is not the immediate priority.

B: Inserting a large-bore IV catheter is necessary for administering medications and fluids but is not the first priority.

C: Ensuring an adequate airway is the priority action. Maintaining airway patency is crucial to prevent respiratory complications and ensure the client receives adequate oxygen.

D: Preparing the appropriate antagonist is important but should follow the immediate action of ensuring an adequate airway.

A. Assess characteristics of her sputum. B. Assess pulse and respirations. C. Instruct to slowly exhale with pursed lips. D. Auscultate lung fields.

Correct Answer is D

Explanation

A: Assessing the characteristics of the sputum is important for understanding the nature of the infection and the effectiveness of the treatment, but it is not the first action to take before the procedure.

B: Assessing pulse and respirations is the first action the nurse should take. This provides baseline data on the client’s respiratory and cardiovascular status, which is crucial for monitoring the client’s response to the procedure and ensuring safety.

C: Instructing the client to slowly exhale with pursed lips is a technique used to improve breathing efficiency and oxygenation, but it is not the first action to take before the procedure.

D: Auscultating lung fields is important for assessing the client’s respiratory status and identifying areas of congestion or decreased breath sounds, but it should follow the initial assessment of pulse and respirations.

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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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