A nurse is calculating a client's fluid intake over the past 8 hours.

The client had one 8-ounce cup of coffee, 3 ounces of juice, and 12 ounces of soda.

The client's water pitcher had 800 mL and 200 mL remaining.

The client also had IV fluids infusing at 40 mL per hour via an IV pump.

How many mL should the nurse document as the client's total intake for the shift?

Answer and Explanation

The Correct Answer is ["1610"]

Step 1: Convert ounces to milliliters for oral intake. 8 ounces of coffee × 30 mL/ounce = 240 mL. 3 ounces of juice × 30 mL/ounce = 90 mL. 12 ounces of soda × 30 mL/ounce = 360 mL.

Step 2: Calculate the amount of water consumed from the pitcher. Initial amount - Remaining amount = Consumed amount. 800 mL - 200 mL = 600 mL.

Step 3: Calculate the total oral fluid intake. Coffee + Juice + Soda + Water = Total oral intake. 240 mL + 90 mL + 360 mL + 600 mL = 1290 mL.

Step 4: Calculate the total IV fluid intake over 8 hours. IV rate × Time = Total IV fluid. 40 mL/hour × 8 hours = 320 mL.

Step 5: Calculate the total fluid intake (oral + IV). Total oral intake + Total IV fluid = Total intake. 1290 mL + 320 mL = 1610 mL.

The nurse should document 1610 mL as the client's total intake for the shift.

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Correct Answer is B

Explanation

Choice A rationale

Sublingual medications are designed to be absorbed directly into the bloodstream through the highly vascular mucous membranes under the tongue. Dissolving it in water and administering it through an NG tube would bypass this route, potentially altering the drug's absorption and effectiveness, as it would then be processed through the gastrointestinal system.

Choice B rationale

Administering the medication under the client's tongue ensures that it is absorbed sublingually, bypassing the gastrointestinal tract. This is the intended route for this medication, allowing for rapid absorption and avoiding potential interactions or degradation in the digestive system. The rich blood supply under the tongue facilitates quick entry into systemic circulation.

Choice C rationale

Requesting an oral formulation might be an option if the sublingual route is absolutely contraindicated, but it doesn't address the immediate situation. Oral medications have different absorption rates and may be unsuitable for a client with an NG tube if they have swallowing difficulties or other gastrointestinal issues.

Choice D rationale

Crushing a sublingual medication and administering it through an NG tube is inappropriate. This alters the intended drug delivery mechanism and could lead to unpredictable absorption, potential blockage of the NG tube, and loss of the medication's intended effect. Sublingual formulations are not designed for enteral administration.

A. Instruct the client to tilt their head back while swallowing. B. Elevate the client's head of the bed to 45° during meals. C. Alternate the client's liquids and solids during meals. D. Encourage the client to lie flat after meals.

Correct Answer is C

Explanation

Choice A rationale

Instructing a client with dysphagia to tilt their head back while swallowing can actually increase the risk of aspiration. This position opens the airway and makes it easier for food or liquid to enter the trachea instead of the esophagus, potentially leading to pneumonia or other respiratory complications.

Choice B rationale

Elevating the client's head of the bed to 45° during meals is a crucial intervention for clients with dysphagia. This semi-Fowler's position helps to utilize gravity to facilitate the passage of food and liquids down the esophagus and reduces the risk of aspiration into the airway. Maintaining this upright posture during and shortly after meals is essential for safe swallowing.

Choice C rationale

Alternating liquids and solids during meals can help manage dysphagia by reducing the bolus size and consistency that the client needs to manage at any given time. This strategy can prevent overwhelming the client's swallowing ability and decrease the risk of aspiration by allowing for better control over different food textures.

Choice D rationale

Encouraging the client to lie flat after meals is contraindicated for clients with dysphagia. Lying flat increases the risk of regurgitation and aspiration of food or liquids into the airway. Clients with swallowing difficulties should remain in an upright or semi-upright position for at least 30-60 minutes after eating to allow for proper digestion and reduce the risk of aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A provider prescribes a sublingual medication for a client who has an nasogastric (NG) tube in place.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has dysphagia.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is contributing to the plan of care of a client who has had a stroke and is experiencing severe dysphagia with choking and coughing while eating. Which of the following nutritional therapies should the nurse expect to include in the plan of care?