The nurse is completing the intake and output record for a preschool-age client admitted for fluid volume deficit.

The client has had the following intake and output during the shift:

Intake:

4 oz of Pedialyte

1/2 of an 8-oz cup of clear orange Jell-O

2 graham crackers

200 mL of D 5-1/2 sodium chloride IV

Output:

345 mL of urine

50 mL of loose stool

The nurse documents the client's intake as milliliters. How much liquidintake did the client have in Milliliters?
Round the answer to the nearest whole number.

Answer and Explanation

The Correct Answer is ["437"]

To convert ounces to milliliters, multiply by 29.57
4 oz of Pedialyte = 118.28 mL
1/2 of an 8-oz cup of clear orange Jell-O = 118.28 mL
2 graham crackers = no liquid intake
200 mL of D 5-1/2 sodium chloride IV = 200 mL
Total intake = 118.28 + 118.28 + 200 = 436.56 mL
Round to the nearest whole number = 437 mL
The nurse documents the client's intake as 437 mL

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Correct Answer is C

Explanation

Choice A reason:

Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.

Choice B reason:

Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.

Choice C reason:

This statement is correct. Confirming placement of the tube prior to each medication

administration is crucial to ensure safe and effective delivery of medications and nutrition.

Choice D reason:

Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.

A. Increased blood pressure B. Hyperactive bowel sounds C. Bradycardia D. Sudden abdominal pain

Correct Answer is D

Explanation

Choice A reason:

Increased blood pressure is not typically associated with gastrointestinal perforation; hypotension may be more indicative.

Choice B reason:

Hyperactive bowel sounds may be present in various gastrointestinal conditions, but they are not specific to perforation.

Choice C reason:

Bradycardia is not a typical sign of gastrointestinal perforation; tachycardia may be more indicative of this condition.

Choice D reason:

This statement is correct. Sudden abdominal pain is a key indication of gastrointestinal perforation, and it should be monitored closely.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

Correct Answer is D

Explanation

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medication's therapeutic action?

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

A patient has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test?

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