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 of the following volumes should the nurse record on the I&O?

440 mL

660 mL

330 mL

550 mL

Answer and Explanation

The Correct Answer is B

A) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

B) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

C) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

D) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

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Correct Answer is ["B","C","E"]

Explanation

A) A client reports being dissatisfied with the temperature of the meals provided. - This situation does not pose a risk to the client's safety or result in harm, so an incident report is not necessary.

B) A client receives burns from a heating pad. - Any incident resulting in harm to the client, such as burns from a heating pad, should be documented with an incident report.
C) A client becomes disoriented and falls out of bed. - Falls resulting in injury or disorientation require documentation via an incident report.
D) A client is unable to afford the physical therapy that the provider recommends. - Financial constraints do not necessitate an incident report.
E) A client's visitor becomes dizzy and faints in the client's room. - Incidents involving visitors, especially if they occur in the client's presence, should be documented with an incident report.

A. Use a narrower cuff to repeat the BP measurement. B. Request a prescription for an antihypertensive medication. C. Deflate the cuff faster when repeating the BP measurement. D. Measure the client's BP in the other arm.

Correct Answer is D

Explanation

A) Use a narrower cuff to repeat the BP measurement. - Using a narrower cuff is not appropriate and may result in inaccurate BP readings.
B) Request a prescription for an antihypertensive medication. - This action is premature based on a single elevated BP reading and should be guided by the provider's assessment and recommendations.
C) Deflate the cuff faster when repeating the BP measurement. - The speed of cuff deflation does not significantly affect BP measurement accuracy, and this action may not address the underlying cause of the elevated BP.
D) Measure the client's BP in the other arm. - Confirming the elevated BP with a reading from the other arm can help determine if the elevation is due to positioning or equipment error.

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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 of the following volumes should the nurse record on the I&O?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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