A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee. 4 oz of orange juice. 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea. 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client’s record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer and Explanation

The Correct Answer is ["1170"]

To calculate the total fluid intake for a client during a 4-hour period, the nurse should convert all the measurements to milliliters (mL) and add them together. One cup is equal to 240 mL, one ounce is equal to 30 mL, and one teaspoon is equal to 5 mL. Therefore, the client consumes:

- 1 cup of coffee = 240 mL

- 4 oz of orange juice = 120 mL

- 3 oz of water = 90 mL

- 1 cup of flavored gelatin = 240 mL

- 1 cup of tea = 240 mL

- 5 oz of broth = 150 mL

- 3 oz of water = 90 mL

The total fluid intake is:

240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL

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Correct Answer is B

Explanation

A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.

B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.

C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.

D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.

A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post meal capillary blood glucose is now 160 mg/dL B. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 D. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous

Correct Answer is B

Explanation

A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.

B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.

C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.

D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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