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 D

Explanation

A. Pain in the affected leg could indicate worsening of cellulitis or a potential complication like deep vein thrombosis (DVT), but there is no immediate indication of a life-threatening condition. This client should be assessed, but may not be the top priority unless other signs of complications are present.

B. A serum calcium level of 10 mg/dL is within the normal range (8.5 to 10.5 mg/dL). A headache, while concerning, is not immediately life-threatening unless there are additional symptoms suggesting something more severe.

C.Reddish brown urine suggests hematuria, a symptom of glomerulonephritis. This could indicate ongoing kidney issues, but unless there are signs of severe kidney failure or systemic infection, this might not be the most urgent case.

D. A blood glucose level of 68 mg/dL is low and can lead to hypoglycemia, which can be immediately life-threatening if it progresses to severe hypoglycemia. Symptoms of hypoglycemia include confusion, dizziness, sweating, and can escalate to seizures or unconsciousness if not promptly treated.

A. A client who is taking a thiazide diuretic B. A client who is vomiting C. A client who has diarrhea D. A client who is having an acute anxiety attack

Correct Answer is C

Explanation

A. A client who is taking a thiazide diuretic:
Thiazide diuretics can cause loss of potassium and metabolic alkalosis, not metabolic acidosis.

B. A client who is vomiting:
Vomiting can lead to the loss of stomach acid (hydrochloric acid) and may result in metabolic alkalosis, not metabolic acidosis.

C. A client who has diarrhea.
Diarrhea can lead to the loss of bicarbonate, an important buffer in the body that helps maintain acid-base balance. The loss of bicarbonate in diarrhea can result in an excess of acid, contributing to metabolic acidosis.

D. A client who is having an acute anxiety attack:
Acute anxiety is not typically associated with metabolic acidosis. It is not directly related to changes in acid-base balance.

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Naxlex Comprehensive Predictor Exams

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that a clients is at risk for metabolic acidosis?

Correct Answer is C

Explanation

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