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

When a nurse receives a new prescription over the telephone from a client's provider, the first action the nurse should take is to write down the complete prescription. This ensures that the nurse has an accurate record of the prescription and can refer to it when administering medication or providing care.

Option a is incorrect because documenting the prescription as a telephone prescription in the medical record is important but not the first action.

Option b is incorrect because reading back the prescription to the provider is important but not the first action.

Option c is incorrect because ensuring that the provider signs the prescription is important but not the first action.

A. Encourage the client to take sips of water. B. Check for gastric residual volume. C. Flush the tube with sterile 0.9% sodium chloride irrigation. D. Encourage the client to breathe deeply and cough.

Correct Answer is B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

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Naxlex Comprehensive Predictor Exams

A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?

Correct Answer is B

Explanation

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