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 D

Explanation

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

A. Place the client in a supine position. B. Withdraw the tube if the client gags during insertion. C. Measure the tube for insertion from the tip of the nose to the umbilicus. D. Instruct the client to place his chin to his chest and swallow.

Correct Answer is D

Explanation

A. Place the client in a supine position.
Placing the client in a high Fowler's position (sitting upright) is the appropriate position for inserting a nasogastric tube. This position helps facilitate the passage of the tube through the nasopharynx and into the esophagus and stomach.

B. Withdraw the tube if the client gags during insertion.
Gagging during insertion is a normal response. Advancing the tube slowly and having the client swallow can help pass the tube through the nasopharynx.

C. Measure the tube for insertion from the tip of the nose to the umbilicus.
The correct measurement for insertion is from the tip of the nose to the earlobe and then down to the xiphoid process (not the umbilicus).

D. Instruct the client to place his chin to his chest and swallow.
This instruction is appropriate. Asking the client to flex their head slightly forward and swallow helps guide the tube into the esophagus.

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Naxlex Comprehensive Predictor Exams

A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following Interventions should the nurse take when inserting the nasogastric tube?

Correct Answer is D

Explanation

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A nurse is reinforcing discharge teaching with a client who has a new diagnosis of gastroesophageal disease (GERD). Which of the following foods should the nurse include in the list of foods the client should avoid?

A nurse is contributing to the plan of care of a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?

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