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 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.

A. Severe diarrhea B. Involvement of the rectal mucosa C. An absence of blood in stool D. A pattern of distinct exacerbations and remissions

Correct Answer is D

Explanation

Choice A reason:

Severe diarrhea can be a symptom of both Crohn's disease and ulcerative colitis and does not specifically indicate one over the other.

Choice B reason:

Involvement of the rectal mucosa is more indicative of ulcerative colitis rather than Crohn's disease, as Crohn's disease can affect any part of the digestive tract.

Choice C reason:

The presence or absence of blood in stool is not a definitive indicator of either Crohn's disease or ulcerative colitis, as both conditions can involve bleeding.

Choice D reason:

This statement is correct. A pattern of distinct exacerbations and remissions is more characteristic of Crohn's disease, whereas ulcerative colitis often presents with continuous, chronic symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the patient's signs and symptoms?

Correct Answer is D

Explanation

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?

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?

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?

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?

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?

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