A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water.
How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.)
The Correct Answer is ["1820"]
1. IV fluids:
- 150 mL/hr * 8 hr = 1200 mL
2. Juice:
- 4 oz * 30 mL/oz = 120 mL
3. Water:
- 0.5 L * 1000 mL/L = 500 mL
Total intake:
- 1200 mL + 120 mL + 500 mL = 1820 mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.
Correct Answer is C
Explanation
A: The client's statement reflects feelings of confusion but does not indicate immediate harm or danger to themselves. It requires therapeutic communication and support but not immediate action.
B: The client's statement expresses concern about their future relationships but does not indicate immediate harm or danger to themselves. It requires support and counseling but not immediate action.
C: Correct. The client's statement suggests significant emotional distress and a potential risk for self-harm or suicidal ideation. Immediate action is required to assess the client's safety and provide appropriate interventions, such as involving a mental health professional.
D: The client's statement indicates dissatisfaction or regret about the mastectomy decision but does not indicate immediate harm or danger to themselves. It requires supportive communication and addressing concerns but not immediate action.
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