A nurse is caring for a client who consumes 3 oz of milk, 2 oz of orange juice, 3 oz of tea, and 4 oz of water over a 4-hr period. The client is also receiving dextrose 5% in 0.45% sodium chloride 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 ["475 "]

To calculate the client's intake for that 4-hr period in ml, we need to convert the liquid amounts from oz to ml using the following formula:

1 ml = oz * 29.5735296

Using this formula, we can convert the milk, orange juice, tea, and water amounts to ml: Milk: 3 oz * 29.5735296 ml/oz = 88.7205888 ml

Orange juice: 2 oz * 29.5735296 ml/oz = 59.1470592 ml

Tea: 3 oz * 29.5735296 ml/oz = 88.7205888 ml

Water: 4 oz * 29.5735296 ml/oz = 118.2941184 ml

The total intake from these liquids is:

88.7205888 + 59.1470592 + 88.7205888 + 118.2941184 = 354.8823552 ml We also need to add the intake from the IV infusion, which is given at a rate of 30 mL/hr for 4 hours:

30 mL/hr * 4 hr = 120 mL

The total intake from the IV infusion is:

120 mL

The total intake for that 4-hr period in ml is:

354.8823552 + 120 = 474.8823552 ml

Rounding the answer to the nearest whole number, we get:

475 ml

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Correct Answer is D

Explanation

The nurse should first palpate the abdomen to assess for signs of appendicitis, such as rebound tenderness, guarding, or rigidity. Appendicitis is a medical emergency that requires prompt diagnosis and treatment to prevent rupture and peritonitis.

A. Administer acetaminophen to the client. B. Complete an incident report C. Document the occurrence in the client's medical record. D. Send the visitor to the risk management office.

Correct Answer is B

Explanation

A nursing incident report is a document that provides detailed information and account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting or facility especially in the nursing side. An incident report is used to communicate important safety information to hospital administrators and keep them updated on aspects of patient care for risk management, quality assurance, educational, and legal purposes. An incident report should be completed within 24 hours by whomever witnessed the incident or was notified first. In this case, the nurse should complete an incident report because the visitor's fall is an unforeseen circumstance that threatens patient safety and could have legal implications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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