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?

Choice A rationale

Placing the client's arms above her head prior to logrolling can cause discomfort and injury, especially after spinal surgery. Arms should be kept at the sides to maintain alignment.

Choice B rationale

Placing the client in semi-Fowler's position before logrolling is incorrect. The semi-Fowler's position is not stable for logrolling and does not align the spine correctly for safe movement.

Choice C rationale

Placing the bed in the lowest position before logrolling can make the process more difficult and unsafe. The bed should be at a height that allows proper body mechanics for the caregiver.

Choice D rationale

Placing a pillow between the client's legs prior to logrolling helps maintain spinal alignment and prevents twisting of the spine, which is crucial after a laminectomy.

The nurse should first: Response 1: Notify the primary health care provider immediately.

This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.

Then, the nurse should: Response 2: Start an IV line for potential medication administration.

Starting an IV line ensures that the client can receive any necessary medications quickly.