The nurse is monitoring the intake and output of an elderly patient at risk for dehydration closely. The patient drank 4 fl oz of orange juice for breakfast, 6 fl oz of apple juice for lunch, and 5 fl oz of cranberry juice for dinner. The unlicensed assistive personnel (UAP) reports the patient drank 1600 mL of water for their entire 12 hour shift. How many mLs should the nurse document as the patient's total input? Please only enter the numeric portion of your answer with no commas, spaces or units in the answer box.
The Correct Answer is ["2044"]
Approximately 29.5735 mL in a fluid ounce. So, the patient drank about 118.294 mL of orange juice (4 fl oz), 177.441 mL of apple juice (6 fl oz), and 147.8675 mL of cranberry juice (5 fl oz). Adding these amounts to the 1600 mL of water gives us a total of 2043.6025 mL.
Therefore, the nurse should document the patient's total intake as 2044 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Reflex tone refers to the neurological response of the body to stimuli and is not directly related to the action or monitoring of anticoagulant therapy. While assessing reflexes might be important for overall patient health, it is not specifically relevant to monitoring the effects of warfarin. Reflex tone does not provide information on the anticoagulation status or risk of bleeding associated with warfarin therapy.
B. Checking the body for bruising helps assess the safety of warfarin therapy and may indicate the need for dosage adjustments or further investigation if bruising is excessive. However, while monitoring for bruising is essential, it is not the primary method for assessing the effectiveness and safety of anticoagulant therapy.
C. While monitoring kidney function is relevant for overall medication management, it is not the primary focus for directly assessing the effectiveness or safety of warfarin therapy. Kidney function is more related to adjusting doses and avoiding potential complications.
D. Regularly reviewing PT is crucial for managing warfarin therapy because it directly reflects the anticoagulation effect of the medication. The International Normalized Ratio (INR), derived from PT, is used to ensure the patient is within the therapeutic range for effective anticoagulation while minimizing the risk of bleeding.
Correct Answer is A
Explanation
A. Older adults often present with atypical symptoms when they have respiratory infections, such as pneumonia. They may not always exhibit classic signs like a cough or significant difficulty breathing. Instead, symptoms might include confusion, changes in mental status, or subtle signs of respiratory distress. This explanation addresses the patient's daughter's concern by acknowledging that older adults can show different manifestations of illness compared to younger people.
B.A This response is misleading. Respiratory problems can develop at any stage of an infection, not only after the infection is well established. Pneumonia can sometimes present without obvious respiratory distress or symptoms, especially in older adults. It’s crucial to recognize that pneumonia can manifest in various ways and early intervention is important.
C. While it's true that older adults may experience decreased muscular strength, this response might be too specific and not fully address the broader issue. It's also possible that the patient has enough strength but is not showing the typical signs of infection. This response might oversimplify the situation and could be seen as dismissive of the patient's actual symptoms.
D. This response, while optimistic, is not entirely appropriate in this context. It might come off as minimizing the daughter's concerns and does not directly address why the patient might not exhibit typical symptoms of pneumonia. It’s important to acknowledge the atypical presentation rather than simply focusing on the timing of the diagnosis.
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