After reviewing the client's intake and output record for the last eight hours, the nurse calculates the client's current fluid balance as how many mL? (Enter numeric value only).

0730-8 oz of orange juice, hard boiled egg, and toast

0830-voided 150 ml

1200-1 cup of soup, tuna sandwich, and 1/2 cup of apple juice

1300 vomitus of 100 mL

1400 voided 250 mL and drank one 12 oz can of soft drink

Answer and Explanation

The Correct Answer is ["455 ml"]

Intake:
- 8 oz of orange juice = 240 mL
- 1 cup of soup = 240 mL
- 1/2 cup of apple juice = 120 mL
- 12 oz can of soft drink = 355 mL
- Total intake = 240 + 240 + 120 + 355 = 955 mL
Output:
- Voided 150 mL
- Vomitus 100 mL
- Voided 250 mL
- Total output = 150 + 100 + 250 = 500 mL
Fluid Balance:
- Fluid balance = Intake - Output = 955 - 500 = 455 mL

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A

Advising the client that too much fruit can irritate the colon is not the right choice. While it's true that excessive consumption of certain fruits can cause gastrointestinal discomfort, this information is not directly related to celiac disease or the selected meal.

Choice B

Informing the client that oatmeal contains gluten is the right choice. Celiac disease is an autoimmune disorder in which consuming gluten, a protein found in wheat, rye, and barley, triggers an immune response that damages the small intestine. Oatmeal itself is naturally gluten-free, but it is often processed in facilities that also process gluten-containing grains, which can lead to cross-contamination. Therefore, it's important for individuals with celiac disease to choose certified gluten-free oats to avoid adverse reactions.

Choice C

Commending the client for selecting fat-free milk is not the best choice. While choosing a healthier milk option is beneficial for overall health, it is not the most important action in this situation, considering the client's celiac disease.

Choice D reason;

Encouraging the client to choose decaffeinated coffee is not the right choice. The choice of caffeinated or decaffeinated coffee is a matter of preference and is not directly related to celiac disease or the potential for gluten exposure from the oatmeal.

A. Beef broth. B. Ketchup. C. Ice cream. D. Bread.

Correct Answer is C

Explanation

Choice A

Beef broth should not be omitted. Generally, clear broths like beef broth are lower in fat and may be a better choice for someone with cholelithiasis compared to creamy or fatty foods.

Choice B

Ketchup should not be omitted. Ketchup is not typically high in fat and may not be a significant concern for someone with cholelithiasis.

Choice C

Ice cream should be omitted. Cholelithiasis refers to the presence of gallstones in the gallbladder. Gallstones can form from substances in the bile, and certain foods can trigger symptoms in individuals with gallbladder issues. One of the common triggers is high-fat foods, which can cause the gallbladder to contract and potentially lead to pain or discomfort.

Choice D

Bread should not be omitted. While bread contains some fat, it's not as high in fat as ice cream. The focus for individuals with cholelithiasis is often on high-fat foods rather than moderate-fat foods like bread.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal. What food choice should the nurse encourage the client to omit?

Correct Answer is C

Explanation

While caring for a client receiving total parenteral nutrition (TPN), it is most important for the nurse to monitor which of the client's lab values?

The charge nurse observes a newly hired nurse who is preparing to insert a nasogastric tube. Which action by the charge nurse takes priority?

A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. What assessment should the nurse complete before contacting the healthcare provider?

The nurse is developing a food safety educational class for a group of parents. Which type of food is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40°F (4.4°C) or below for more than two days?

The nurse is preparing the client for discharge and discussing home medications. What home medications may affect the amount of insulin needed by the client? Select all that apply.

A female client with haemorrhoids tells the nurse that she understands the need to avoid eating nuts and seeds to prevent inflammation. How should the nurse respond?

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon returning home. Which dietary teaching should the nurse include in the discharge instructions?