The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

Answer and Explanation

The Correct Answer is ["594.882 mL"]

To calculate the fluid intake, you need to convert each type of drink to millilitres (mL) and then sum them up:

Oatmeal: Oatmeal is usually consumed as a solid, so it doesn't contribute to fluid intake.

Cup of milk: Depending on the size of the cup, let's assume it's 240 mL (a common serving size for a cup of milk).

12 ounces of coffee: Convert ounces to millilitres. 1 fluid ounce is approximately 29.5735 mL, so 12 ounces is roughly 354.882 mL.

Total fluid intake = Milk + Coffee Total fluid intake = 240 mL + 354.882 mL Total fluid intake = 594.882 mL

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Correct Answer is B

Explanation

Choice A

Client with a nasogastric tube to low, intermittent suction is not correct. While there is a risk of aspiration with a nasogastric tube in place, the tube is intended to help drain stomach contents, reducing the risk of aspiration. However, if the tube is not properly positioned or managed, there could still be some risk.

Choice B

Client who has sensory aphasia and is receiving a clear liquid diet is correct. Sensory aphasia refers to a language disorder that affects a person's ability to understand language and communication. This client may have difficulty swallowing safely and effectively, which increases the risk of aspiration. Additionally, a clear liquid diet consists of thin liquids that are more likely to be aspirated compared to thicker fluids.

Choice C

Client receiving 30% oxygen via a non-rebreather face mask is not correct. Oxygen therapy can increase the risk of drying the airways and potentially increasing the risk of aspiration, but if the oxygen mask is properly fitted and humidified, the risk may be minimized.

Choice D

Client experiencing dysphagia who is prescribed a full liquid diet is not correct. Dysphagia refers to difficulty swallowing, which can increase the risk of aspiration. However, a full liquid diet includes thicker liquids that are less likely to be aspirated compared to thin liquids. Still, the risk of aspiration exists, especially if the client has severe dysphagia.

A. Canned cream of mushroom soup, tuna salad, and water. B. Bacon. lettuce, and tomato sandwich, grapes, and skim milk. C. Taco salad, refried beans, low fat ice cream and coffee. D. Chicken salad on toast, fruit-flavoured yogurt, and iced tea.

Correct Answer is B

Explanation

Choice A

Canned cream of mushroom soup, tuna salad, and water is inappropriate. Canned soups and processed foods like canned cream soups can be high in sodium. Tuna salad might also have added salt.

Choice B
B. Bacon, lettuce, and tomato sandwich, grapes, and skim milk is the appropriate selection. A serum sodium level of 155 mEq/L (155 mmol/L) is higher than the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L), indicating hypernatremia or high blood sodium levels. In this case, it's important for the client to choose foods that are lower in sodium to help manage their sodium intake.

Choice C

Taco salad, refried beans, low-fat ice cream, and coffee is inappropriate. Taco salad can contain salty ingredients, and refried beans can also be high in sodium. Processed meats and sauces used in tacos can contribute to sodium intake.

Choice D

Chicken salad on toast, fruit-flavoured yogurt, and iced tea is inappropriate. Chicken salad and some breads might contain added salt. Fruit-flavoured yogurts can also have added sugars, and iced tea can vary in sodium content depending on how it's prepared.

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The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is at greatest risk for aspiration?

Correct Answer is B

Explanation

A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]

Correct Answer is B

Explanation

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