A nurse is calculating a client's fluid intake over the past 8 hr. The client had one 8-oz cup of coffee, 3 oz of juice, and 12 oz of soda. The client's water pitcher had 300 ml and 200 ml remains. The client also had IV fluids infusing as 40 mL/hr via an infusion pump. How many ml should the nurse document as the client's total Intake for the shift?

Answer and Explanation

The Correct Answer is ["1110"]

8-oz cup of coffee = 8 oz (since 1 fluid ounce is approximately 30 ml, this is roughly 240 ml).

3 oz of juice = 3 oz (approximately 90 ml).

12 oz of soda = 12 oz (approximately 360 ml).

Water pitcher had 300 ml, and 200 ml remains, so the client consumed 300 ml - 200 ml = 100 ml of water.

IV fluids infusing at 40 mL/hr for 8 hours = 40 ml/hr * 8 hr = 320 ml.

Now, sum up these values:

240 ml (coffee) + 90 ml (juice) + 360 ml (soda) + 100 ml (water) + 320 ml (IV fluids) = 1,110 ml
So, the nurse should document the client's total intake for the shift as 1,110 ml.

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Correct Answer is B

Explanation

A. Slight bleeding of the stoma site: This is typically normal in the immediate postoperative period. It's caused by surgical trauma and should improve with time. However, if it becomes excessive, it should be reported.

B. Purplish colored stoma: A purplish or bluish color of the stoma can be an indication of inadequate blood supply (ischemia). This is a concerning finding and should be reported promptly to the provider.

C. No stool noted in the collection bag: It's normal not to have stool in the collection bag immediately after surgery since the digestive system needs time to resume normal function. This is usually not a concern within the first 12 hours postoperatively. However, if it continues beyond this time frame, it should be reported.

D. Edematous stoma: Some edema or swelling around the stoma site can be normal initially after surgery. However, if the stoma becomes significantly edematous or starts to compromise blood flow, this should be reported to the provider.

A. Monitor the client for manifestations of fluid overload. B. Use alcohol hand sanitizer following client care. C. Disinfect equipment with bleach solution. D. Implement neutropenia isolation.

Correct Answer is C

Explanation

A. Monitor the client for manifestations of fluid overload: This action is not specifically related to C. difficile infection. Monitoring for fluid overload might be necessary in other situations, but it is not the appropriate action for this scenario.

B. Use alcohol hand sanitizer following client care: While alcohol-based hand sanitizers are effective against many pathogens, they are not effective against C. difficile spores. Washing hands with soap and water is necessary to remove the spores.

C. Disinfect equipment with bleach solution. This is the correct answer. Clostridium difficile (C. difficile) spores are resistant to many disinfectants, but they are killed by bleach. Therefore, equipment and surfaces should be cleaned with a bleach solution to prevent the spread of the infection.

D. Implement neutropenia isolation: Neutropenia isolation is a precautionary measure taken when a person has a low count of neutrophils, a type of white blood cell. This option is not directly related to C. difficile infection.

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