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 B

Explanation

Choice A reason:

Removing the NG tube without further attempts to unclog it may not be necessary and could be an unnecessary intervention.

Choice B reason:

This statement is correct. Attempting to unclog the NG tube with warm water and an in-and-out motion is an appropriate next step.

Choice C reason:

Flicking the tube with the fingers may not be effective in dislodging the clog, and it could potentially cause harm to the patient.

Choice D reason:

Withdrawing the tube 3 to 5 cm may not effectively address the clog and could potentially lead to complications.

A. Keep the patient in a low Fowler's position when at rest. B. Connect the tube to continuous wall suction when not in use. C. Confirm placement of the tube prior to each medication administration. D. Have the patient sip cool water to stimulate saliva production.

Correct Answer is C

Explanation

Choice A reason:

Keeping the patient in a low Fowler's position may be helpful for some patients with dysphagia, but it is not a specific intervention related to NG tube care.

Choice B reason:

Connecting the tube to continuous wall suction when not in use is not a standard practice for NG tube care. Continuous suction can cause mucosal damage and discomfort for the patient.

Choice C reason:

Confirming the placement of the NG tube prior to each medication administration is a crucial safety measure. Incorrect placement can lead to serious complications.

Choice D reason:

Sipping cool water to stimulate saliva production may be beneficial for some patients with dysphagia, but it is not a specific intervention related to NG tube care. The focus should be on confirming the placement of the tube.

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Naxlex Comprehensive Predictor Exams

A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

Correct Answer is B

Explanation

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

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