1oz= 29.57 mL

Total oral intake= 3+2+3+4= 12oz 12oz x 29.57= 354.84 ml

Total IV 30ml/hr x 4= 120 ml Total= 354.84 +120

= 474.84 ml

= 475 ml (rounded off to the nearest whole number)

Choice A rationale: Placing the lid face down on the sterile drape contaminates the sterile field, as the outer surface of the lid is not considered sterile.

Choice B rationale: Applying sterile gloves before opening the bottle of sterile solution is important to maintain asepsis and prevent contamination of the field.

Choice C rationale: Pouring sterile solution with the bottle held 20 cm (8 in) above the sterile bowl helps prevent contamination by minimizing the risk of airborne microorganisms entering the solution.

Choice D rationale: Holding the bottle with the label facing the palm helps prevent drips or spills on the label, maintaining the sterility of the solution.

Choice A rationale: Crackles in the lungs indicate fluid overload, as excess fluid can accumulate in the alveoli, causing crackling sounds during breathing.

Choice B rationale: Bradycardia is not typically associated with fluid overload; tachycardia is a more common sign.

Choice C rationale: Fever is not a direct indicator of fluid overload but may be associated with other conditions.

Choice D rationale: Flattened neck veins are not indicative of fluid overload; distended neck veins are more likely to be seen in this condition.

Choice A rationale: While risk management may be involved later, the immediate action is to complete an incident report to document the details of the visitor's fall.

Choice B rationale: Administering acetaminophen to the client is not relevant to the visitor's fall and limp.

Choice C rationale: Documenting the occurrence in the client's medical record is important, but completing an incident report is the priority to ensure a thorough investigation and follow-up.

Choice D rationale: Completing an incident report is the priority to ensure a thorough investigation and follow-up. It is crucial for maintaining an accurate record of the event, identifying potential hazards, and implementing preventive measures.

Choice A rationale: Cleaning electrical equipment is important for infection control but is not directly related to electrical safety.

Choice B rationale: Disconnecting electrical equipment by grasping the plug is a safe practice, as pulling on the cord can damage the cord and create a safety hazard.

Choice C rationale: Taping electrical cords to the floor can create a tripping hazard and is not recommended for electrical safety.

Choice D rationale: Covering exposed wires with tape is not a recommended practice, as it may not provide adequate protection and can create a fire hazard.

Choice A rationale: The client's admitting diagnosis is not a reliable identifier for confirming the client's identity.

Choice B rationale: The client's telephone number is a unique identifier and can be used to confirm the client's identity before administering medications.

Choice C rationale: The name of the client's next of kin is not a direct identifier of the client and should not be used for confirmation.

Choice D rationale: The client's room number is not a unique identifier and may not accurately confirm the client's identity.

Choice A rationale: To perform the test, the nurse should strike a tuning fork and place its base on the top of the client's head. The client should then report if they hear the sound equally in both ears, or louder in one ear. If the sound is louder in one ear, it indicates that there is either a conductive hearing loss in that ear, or a sensorineural hearing loss in the opposite ear.

Choice B rationale: Placing the base of a vibrating tuning fork on the client's mastoid process is the technique for the Rinne's test and not Weber’s test.

Choice C rationale: Counting how many seconds a client can hear a tuning fork after it has been struck is not a component of the Weber's test.

Choice D rationale: Moving a vibrating tuning fork in front of the client's ear canals one after the other is not the correct procedure for the Weber's test but is instead used in Rinne test.

Choice A rationale: Wearing makeup during surgery is typically discouraged to prevent interference with monitoring equipment and to maintain a sterile environment.

Choice B rationale: Explaining the need to have another adult drive the client home is important due to the potential effects of anesthesia, which can impair the client's ability to drive and make decisions.

Choice C rationale: Showering three times the day before surgery is excessive and not a standard preoperative practice.

Choice D rationale: The client should stop drinking clear liquids 2 hrs before surgery. However, the guidelines for fasting but may vary depending on institutional policies.

Choice A rationale: The nurse should instruct the client to relax their arm and keep their hand open, but not to flex their arm, as this can reduce blood flow and make the vein less prominent.

Choice B rationale: Applying a cool compress to the vein for 10 minutes may cause vasoconstriction and make the vein less dilated.

Choice C rationale. Stroking the skin near the vein in an upward direction is incorrect. Stroking should be done in a downward direction, toward the fingers, to help push blood into the vein and make it more visible.

Choice D rationale. Dangling the client's arm over the edge of the bed is correct. This helps use gravity to promote venous filling, making the veins more prominent and easier to access for IV insertion.

Choice A rationale: Using distractions, such as music or gentle conversation, can help make the bathing experience more comfortable for a client with dementia.

Choice B rationale: Giving detailed instructions may be confusing for a client with dementia, as they may have difficulty processing and remembering information.

Choice C rationale: If the client is in distress during the bath, it is essential to modify the approach or consider alternative methods to ensure their comfort and well-being.

Choice D rationale: Allowing the client to select the temperature of the bath water may pose a safety risk, as they may not accurately assess or communicate their preferences.