A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?
The Correct Answer is ["1712.32"]
To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:
1,000 mL 0.9% sodium chloride IV (no conversion needed)
One 6-oz cup of coffee:
6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL
6 oz of water:
6 oz * 29.5735 = approximately 177.44 mL
One 180-mL bowl of soup (no conversion needed)
3 oz of flavored gelatin:
3 oz * 29.5735 = approximately 88.72 mL
3 oz of ice cream:
3 oz * 29.5735 = approximately 88.72 mL
Now, let's add up all the volumes:
1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL
Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
To calculate the infusion rate in mL/hr, you can use the formula:
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
In this case, the total volume is 1000 mL and the total time is 8 hours.
Infusion rate = 1000 mL / 8 hr
Infusion rate ≈ 125 mL/hr
The nurse should set the IV pump to deliver approximately 125 mL/hr.
Correct Answer is B
Explanation
A. Administer aspirin:
Aspirin is commonly given to patients suspected of having a heart attack because it helps to inhibit platelet aggregation and reduce the risk of further clot formation. However, the administration of aspirin typically follows the confirmation of a cardiac event through diagnostic tests like the ECG. Aspirin is not the initial priority compared to obtaining diagnostic data.
B. 12 Lead Electrocardiography (ECG):
This is the most critical and time-sensitive action because it helps to quickly assess the patient's cardiac status. A 12 Lead ECG can identify important findings such as ST-segment elevation or depression, which are indicative of acute myocardial infarction (heart attack) or other cardiac abnormalities. Early detection and intervention are crucial in improving outcomes for patients with suspected cardiac events.
C. Assess vital signs:
Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide valuable information about the patient's overall condition and can help determine the severity of the cardiac event. While assessing vital signs is important, performing the ECG takes precedence due to its immediate relevance in diagnosing and managing a potential cardiac emergency.
D. Administer morphine:
Morphine may be indicated for pain relief in patients with acute coronary syndromes. However, its administration should be based on the patient's pain level, hemodynamic stability, and other factors assessed after obtaining the ECG and vital signs. Morphine administration is not the primary action within the first 10 minutes of the patient's arrival; it follows the initial assessment and diagnostic procedures.
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