A client is admitted to the unit at 1500. The provider has prescribed a full liquid diet for the client. The client ingests the following from 1600 to 2115:

Chicken broth: 120 mL

Tea: 4 ounces

Ice cream: 1 cup

Soda: 6 ounce can

Water: 550 mL

Ice chips: 500 mL

The client voids the following:

At 1530: 400 mL

At 2015: 775 mL

At 2245: 200 mL

Calculate the cumulative fluid intake for the 3 p.m. to 11 p.m. shift. Note that intake and output is calculated at 2200 for the 3 p.m.-11 p.m. shift. (Round to the nearest whole number, use a preceding zero, do not use trailing zeros)

Answer and Explanation

The Correct Answer is ["1705"]

To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.

First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.

Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.

Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.

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Correct Answer is ["A","B","D"]

Explanation

A. This is the part of the IV administration set that pierces the IV bag or bottle to allow fluid to flow into the tubing. The plastic insertion spike must remain sterile because it comes into direct contact with the fluid within the IV container. Contamination of the spike could introduce microorganisms into the IV solution.

B. The catheter adapter or hub is the part of the IV administration set where the IV catheter or cannula connects. It is crucial for this part to remain sterile to prevent introducing pathogens into the bloodstream during catheter insertion or manipulation.

D. The Y-site injection port is a branching point in the IV tubing where additional medications or fluids can be infused into the IV line. It must remain sterile to prevent contamination when administering medications or secondary infusions.

C. The drip chamber is located in the IV tubing, just below the IV bag or bottle. It is designed to visualize and regulate the flow of IV fluid into the patient. It does not directly contact the bloodstream or the IV fluid inside the tubing.

E. Roller clamp to regulate flow (Option E) does not necessarily need to be sterile because it does not come into direct contact with IV fluid or the patient's bloodstream. However, it should be handled with clean hands to maintain general cleanliness and to prevent contamination of other sterile parts of the IV set.

A. Monitoring intake and output B. Providing good mouth and skin care C. Obtaining daily weights D. Assessing level of consciousness E. Administering a loop diuretic

Correct Answer is ["A","B","C","D"]

Explanation

A. Monitoring intake (fluids taken orally or intravenously) and output (urine, vomitus, diarrhea) helps assess fluid balance and hydration status. It is essential in clients with vomiting and diarrhea to prevent dehydration or fluid overload.

B. Vomiting and diarrhea can lead to dehydration and electrolyte imbalances, which may affect the skin and oral mucosa. Providing good mouth care (e.g., oral hygiene, hydration) and skin care (e.g., gentle cleansing, moisturizing) helps maintain comfort and prevent complications such as skin breakdown.

C. This may be appropriate depending on the severity of the client's condition and the healthcare provider's orders. Daily weights help monitor fluid balance and assess for changes in hydration status. However, in acute cases of vomiting and diarrhea, more frequent weights or other assessments of fluid status may be necessary.

D. Assessing the client's level of consciousness is important to monitor for signs of dehydration or electrolyte disturbances, which can affect neurological function. Changes in level of consciousness may indicate worsening dehydration or other complications that require prompt intervention.

E. Loop diuretics are medications used to increase urine output by inhibiting sodium reabsorption in the kidneys. However, they are not indicated for treating vomiting and diarrhea. In fact, administering diuretics could exacerbate fluid and electrolyte imbalances in a client who is already experiencing fluid loss through vomiting and diarrhea

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Naxlex Comprehensive Predictor Exams

The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)

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Explanation

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Correct Answer is ["A","B","C","D"]

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