A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of 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 ["732"]

To calculate the total intake, we need to convert all measurements to the same unit, in this case, milliliters (mL).

1 ounce (oz) is approximately equal to 29.5735 mL.

Also, it’s important to note that when ice chips melt, they become about half their volume in water. So, 100 mL of ice chips would become about 50 mL of wate

Let’s calculate:

Juice: 4 oz * 29.5735 = 118.294 mL

Tea: 6 oz * 29.5735 = 177.441 mL

Ice chips: 100 mL * 0.5 = 50 mL

IV bolus: 150 mL

Broth: 8 oz * 29.5735 = 236.588 mL

Adding all these together:

118.294 mL (juice) + 177.441 mL (tea) + 50 mL (ice chips) + 150 mL (IV bolus) + 236.588 mL (broth) = 732.323 mL

So, the nurse should record 732 mL of intake on the client’s record (rounded to the nearest whole number).

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Correct Answer is A

Explanation

A) Peanut butter:
Peanut butter is high in phenylalanine, the amino acid that individuals with phenylketonuria (PKU) are unable to metabolize properly. Therefore, individuals with PKU should avoid consuming foods high in phenylalanine, such as peanut butter.

B) Broccoli
C) Apple juice
D) Potatoes:
These foods are low in phenylalanine and do not need to be eliminated from the client's diet. In fact, they can provide essential nutrients during pregnancy. However, the client should be encouraged to consume foods that are low in phenylalanine to prevent complications associated with PKU.

A. Inform the client the anesthetic effect will last for approximately 6 hr. B. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. C. Administer a 500 mL bolus of 5% dextrose in water prior to induction. D. Have the client stand at the bedside with her arms at her side.

Correct Answer is B

Explanation

A) Inform the client the anesthetic effect will last for approximately 6 hr:
This statement is inaccurate. While the duration of the analgesic effect may vary, epidural analgesia typically provides pain relief for the duration of labor. It is not appropriate to provide a specific time frame like 6 hours as the duration can vary widely depending on the type of medication used and individual response.

B) Obtain a 30-min electronic fetal monitoring (EFM) strip prior to induction:
This is the correct action. It is essential to obtain a baseline fetal heart rate tracing for at least 20-30 minutes prior to initiating epidural analgesia. This allows the healthcare team to assess the fetal status and identify any baseline abnormalities before the initiation of anesthesia.

C) Administer a 500 mL bolus of 5% dextrose in water prior to induction:
This action is not directly related to the preparation for epidural analgesia. Providing a dextrose solution is not a standard practice before epidural placement.

D) Have the client stand at the bedside with her arms at her side:
This action is not appropriate for preparing a client for epidural analgesia. The client should be in a comfortable position, such as sitting or lying on the side, for the procedure.

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A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of 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

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

Correct Answer is A

Explanation

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

A nurse is preparing to administer lithium 300 mg PO every 8 hr. Available is lithium carbonate 150 mg capsules. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?