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?

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.

Choice A rationale

Light palpation is typically performed after auscultation to assess for superficial tenderness, muscle tone, and pulsations. Auscultation precedes palpation to avoid inducing artificial bowel sounds or altering existing ones due to manual pressure.

Choice B rationale

Auscultation of bowel sounds in all four quadrants is the next step in the abdominal assessment after inspection. Listening to bowel sounds provides information about the motility of the gastrointestinal tract and should be done before palpation or percussion, which can alter these sounds.

Choice C rationale

Percussion for tones in all four quadrants is usually performed after auscultation and before palpation. Percussion helps to assess the size and density of abdominal organs and to identify the presence of fluid or air.

Choice D rationale

Deep palpation is performed last in the abdominal assessment sequence to evaluate for deeper masses and aortic pulsations. It follows inspection, auscultation, and light palpation, allowing the nurse to gather preliminary information before applying deeper pressure. .