A nurse is recording the intake and output (I&O) for a client.
The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits.
Which volume should the nurse record on the I&O?
The Correct Answer is ["660"]
Step 1: Convert all liquid intake to mL: 8 oz of milk = 8 oz × 30 mL/oz = 240 mL 10 oz of water = 10 oz × 30 mL/oz = 300 mL 4 oz of gelatin = 4 oz × 30 mL/oz = 120 mL
Step 2: Sum the liquid intake: Total intake = 240 mL + 300 mL + 120 mL = 660 mL
The nurse should record 660 mL on the I&O.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Documenting the refusal in the client's medical record is important for legal and clinical reasons, ensuring there's a record of the client's decision and the nurse's response. However, it doesn't address the client's immediate concerns or needs.
Choice B rationale
Returning the medication to the medication cabinet is a necessary step to ensure medication safety and avoid accidental administration. Yet, it does not address the client's reasons for refusal or the potential risks involved.
Choice C rationale
The nurse’s first action should be to provide client education about the importance of taking the medication and the potential consequences of refusal (e.g., increased blood pressure, risk of stroke or heart attack). Addressing the client’s concerns about side effects can encourage adherence or lead to an alternative treatment plan.Client autonomy is respected, but ensuring informed refusal is part of the nurse’s role.
Choice D rationale
The provider should be informed, but only after the nurse has attempted to educate and address the client’s concerns. The provider may adjust the prescription if side effects are problematic.
Correct Answer is A
Explanation
Choice A rationale
"Tell me more about what happens at mealtime.”. This response encourages the caregiver to share detailed information about mealtime routines and behaviors, which can help the nurse identify underlying issues and suggest appropriate strategies.
Choice B rationale
"They may need a feeding tube.”. This suggestion can be alarming and may not be appropriate without understanding the full context of the client's eating habits. Feeding tubes are considered only when other interventions have failed.
Choice C rationale
"Have you tried offering different foods?" While this might be helpful, it does not address the underlying issues. Gathering more information about the current mealtime situation is crucial before suggesting specific interventions.
Choice D rationale
"Let's discuss ways to encourage their appetite.”. This response is proactive but still doesn't gather enough information about the current situation. Understanding the specifics of mealtime behavior is necessary to provide tailored advice.
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