A nurse is calculating the total fluid intake for a patient over a 4-hour period.
The patient consumed 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.
How many mL of intake should the nurse record on the patient’s chart?
The Correct Answer is ["1160"]
Step 1: Convert All Fluid Intake to Milliliters (mL)
To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:
- 1 cup of coffee = 240 mL
- 4 oz of orange juice = 118.3 mL
- 3 oz of water = 88.7 mL
- 1 cup of flavored gelatin = 236.6 mL
- 1 cup of tea = 240 mL
- 5 oz of broth = 147.9 mL
- 3 oz of water (another serving) = 88.7 mL
Step 2: Calculate Total Fluid Intake
Add all the converted fluid amounts together:
- Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL
Step 3: Round to the Nearest Whole Number
Round the total to the nearest whole number:
- Rounded total = 1,160 mL
The nurse should record 1,160 mL on the patient’s chart.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Swabbing an area of skin away from the wound to identify the usual flora is not the correct action. This would not provide a representative sample of the wound infection.
Choice B rationale
Irrigating the wound with an antiseptic prior to obtaining the specimen is not the correct action. This could potentially alter the results of the culture.
Choice C rationale
Cleansing the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen is the correct action. This helps to remove surface bacteria and ensures a more accurate culture result.
Choice D rationale
Including intact skin at the wound edges in the culture is not the correct action. This could contaminate the specimen with bacteria that are not part of the wound infection.
Correct Answer is D
Explanation
Choice A rationale
The shoulder is not the correct fetal presentation in this case. The shoulder presentation, also known as a transverse lie, occurs when the fetus is positioned horizontally in the uterus, and the shoulder is the presenting part. This is not the case in an RSA (Right Sacrum Anterior) position, which indicates a breech presentation.
Choice B rationale
The vertex presentation, also known as a cephalic presentation, occurs when the fetus is positioned head down in the uterus. However, in an RSA position, the fetus is in a breech presentation, not a vertex presentation.
Choice C rationale
The mentum (face) presentation is a rare type of fetal presentation where the neck of the fetus is hyperextended, and the face presents at the cervix. This is not the case in an RSA position, which indicates a breech presentation.
Choice D rationale
In an RSA (Right Sacrum Anterior) position, the fetus is in a breech presentation. This means that the buttocks or feet of the fetus are positioned to enter the birth canal first. Therefore, the nurse should document a breech presentation in the patient’s medical record.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.