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","D","E"]
Explanation
A: A client with lactose intolerance does not have an increased risk of aspiration while eating. Lactose intolerance affects the digestive system, causing symptoms like bloating and diarrhea when consuming dairy products, but it does not impact swallowing.
B: A client who has had a cerebrovascular accident (CVA) or stroke is at increased risk of aspiration. Strokes can affect the muscles involved in swallowing, leading to dysphagia (difficulty swallowing) and increasing the risk of food or liquid entering the airway.
C: A client who has had prolonged diarrhea is not typically at increased risk of aspiration. Diarrhea affects the gastrointestinal system but does not directly impact the swallowing mechanism.
D: A client who has had trauma to the head and neck is at increased risk of aspiration. Such trauma can damage the structures involved in swallowing, leading to dysphagia and a higher likelihood of aspiration.
E: A client who is 4 hours postoperative following a leg amputation with general anesthesia is at increased risk of aspiration. General anesthesia can depress the gag reflex and swallowing function, making it easier for food or liquid to enter the airway during the immediate postoperative period.
Correct Answer is C
Explanation
A: Hyperkalemia refers to high potassium levels, which can occur in ESKD but does not directly cause shortness of breath, swelling, or crackles in the lungs.
B: Hyponatremia refers to low sodium levels, which can occur in ESKD but does not directly cause the symptoms described.
C: Hypervolemia, or fluid overload, is the most likely cause of the client’s symptoms. ESKD can lead to fluid retention, causing shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.
D: Hypovolemia refers to low blood volume, which would not cause the symptoms of fluid overload described in the client.
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