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
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Correct Answer is D
Explanation
Choice A rationale
Constipation is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.
Choice B rationale
Weight gain of 5 lb in 1 month could be a side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.
Choice C rationale
Insomnia is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.
Choice D rationale
Muscle stiffness could be a sign of a serious side effect of aripiprazole known as extrapyramidal symptoms. This could include conditions such as dystonia, akathisia, and Parkinsonism. If a patient experiences muscle stiffness while taking aripiprazole, the healthcare provider should be notified.
Correct Answer is D
Explanation
Choice A rationale
A patient’s address is indeed an example of personally identifiable information. This statement is correct and does not indicate a need for further teaching.
Choice B rationale
HIPAA is indeed a federal law, not a state law. This statement is correct and does not indicate a need for further teaching.
Choice C rationale
HIPAA did establish regulations of individually identifiable health information in verbal, electronic, or written form. This statement is correct and does not indicate a need for further teaching.
Choice D rationale
Information about a client cannot be disclosed to family members at any time without the client’s consent. This statement indicates a need for further teaching.
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