A nurse is caring for a client who consumes 3 ounces of milk, 2 ounces of orange juice, 3 ounces of tea, and 4 ounces of water over a 4-hour period. The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Calculate the client’s intake for that 4-hr period in mL.

(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 ["480"]

480 mL.

The client's total oral intake over the 4-hour period is 3 ounces of milk + 2 ounces of orange juice + 3 ounces of tea + 4 ounces of water = 12 ounces. Since there are approximately 30 mL in 1 ounce, the client's oral intake in mL is 12 ounces * 30 mL/ounce = 360 mL.

The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Over a 4-hour period, the client will receive a total of 30 mL/hr * 4 hours = 120 mL from the IV infusion.

Therefore, the client's total intake for that 4-hour period is 360 mL (oral intake. + 120 mL (IV infusion) = 480 mL.

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Correct Answer is D

Explanation

The correct answer is choice d. Begin by testing the client while they are wearing glasses. Choice A rationale: Positioning the client 3.3 meters (10 feet) away from the chart is incorrect because the standard distance for the Snellen chart is 20 feet (6 meters). Choice B rationale: Documenting the largest line the client can read on the chart is part of the procedure, but it is not the initial action the nurse should take. The nurse must first ensure the client is wearing their glasses to get an accurate assessment. Choice C rationale: Instructing the client to begin the assessment with both eyes open is incorrect because visual acuity is typically tested one eye at a time, with the other eye covered. Choice D rationale: Beginning by testing the client while they are wearing glasses is correct because it provides the most accurate assessment of the client’s visual acuity in their usual state, ensuring the glasses are effectively correcting their vision

A. Faxing medical information to the client's provider's office B. Teaching the client discharge instructions with his partner present C. Discussing the client's transfer to a long-term care facility with a nurse from another unit D. Giving a telephone report to a surgical nurse when sending the client to the surgical suite

Correct Answer is C

Explanation

The correct answer is that discussing the client's transfer to a long-term care facility with a nurse from another unit is a violation of HIPA

A. HIPAA regulations require that healthcare providers protect the privacy of their clients' personal health information (PHI) and only share it with authorized individuals on a need- to-know basis.

Options a, b and d are not violations of HIPAA. Faxing medical information to the client's provider's office, teaching the client discharge instructions with his partner present and giving a telephone report to a surgical nurse when sending the client to the surgical suite are all acceptable practices under HIPAA regulations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPAA?

Correct Answer is C

Explanation

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