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
Suggesting that the family member contact a grief counselor may be helpful, but it does not address their immediate need to help. Involving the family member in care can provide emotional support and a sense of purpose.
Choice B rationale
Describing a personal experience with the death of a family member may offer empathy but can shift the focus away from the client's needs. It is essential to keep the conversation centered on the family member's desire to help.
Choice C rationale
Including the family member in providing care for the client is an appropriate action. It allows them to participate actively, provides emotional support, and can be comforting for both the client and the family member.
Choice D rationale
Asking if the family member has had prior experience with the death of a family member may be relevant but does not directly address their desire to help. It is more effective to involve them in the care process immediately. .
Correct Answer is C
Explanation
Choice A rationale
Applying suction while inserting the catheter is incorrect and can cause tissue damage and hypoxia. Suction should only be applied while withdrawing the catheter to prevent injury to the tracheal mucosa.
Choice B rationale
Applying intermittent suction for up to 30 seconds is excessive and can cause hypoxia and trauma to the trachea. The correct duration for intermittent suctioning is 10-15 seconds per pass to minimize these risks.
Choice C rationale
Preoxygenating the client prior to suctioning helps prevent hypoxia by ensuring the client has adequate oxygen reserves during the procedure. This is a standard practice to enhance patient safety during suctioning.
Choice D rationale
Instructing the client to swallow during catheter insertion is inappropriate and can lead to gagging or aspiration. The client should be relaxed and still during insertion to prevent complications.
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