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A nurse is documenting a client’s fluid intake over the past 8 hours.
Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

2 cups of soup

1 quart of water

8 oz of ice chips

6 oz of tea

Answer and Explanation

The Correct Answer is C

Choice A rationale

A cup of soup is typically 240 mL, so 2 cups would be 480 mL, which is more than 120 mL1.

Choice B rationale

A quart is a unit of volume equal to 946 mL, which is significantly more than 120 mL1.

Choice C rationale

8 oz of ice chips is approximately equivalent to 120 mL2. This is because when ice melts, it reduces in volume by about half, so 8 oz of ice chips would melt to about 4 oz of water, which is approximately 120 mL2.

Choice D rationale

6 oz is approximately 177 mL, which is more than 120 mL2.

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Correct Answer is A

Explanation

Choice A rationale

After drawing up the medication, the nurse should ask another nurse to observe the medication wastage. This is a standard procedure for controlled substances like opioids. The second nurse acts as a witness to ensure that the unused portion of the medication is disposed of properly and not diverted for inappropriate use.

Choice B rationale

Notifying the pharmacy when wasting the medication is not the immediate next step after drawing up the medication. While some institutions may require notification of the pharmacy for controlled substance wastage, the immediate next step is typically to have another nurse witness the wastage.

Choice C rationale

Locking the remaining medication in the controlled substances cabinet is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

Choice D rationale

Disposing of the vial with the remaining medication in a sharps container is not the immediate next step after drawing up the medication. The remaining medication should be wasted with a witness present.

A. The top of the cane is parallel to the patient’s waist. B. The patient advances the cane 46 cm (18 in) forward while walking. C. The patient holds the cane on the side of their body that is stronger. D. The patient moves their stronger leg forward along with the cane.

Correct Answer is C

Explanation

Choice A rationale

While the top of the cane should be parallel to the client’s greater trochanter, this alone does not indicate correct use of the cane.

Choice B rationale

Advancing the cane 46 cm (18 in) forward while walking is too far. To maintain balance, the client should advance the cane about 15-30 cm (6-12 in) at a time.

Choice C rationale

The client should hold the cane on the stronger side of their body to increase support and maintain alignment. This is an indication of correct use.

Choice D rationale

The client should move their weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg.

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A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

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A nurse is documenting a client’s fluid intake over the past 8 hours.
Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?