A nurse is caring for a client who is postoperative and has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?

Lower the head of the client’s bed.

Check the client’s gag reflex.

Remove the client’s peripheral IV.

Check the client for bladder distention.

Answer and Explanation

The Correct Answer is B

A: Lowering the head of the client’s bed is not appropriate in this situation. It does not address the safety concern related to swallowing.

B: Checking the client’s gag reflex is the correct action. This ensures that the client can safely swallow ice chips without the risk of aspiration.

C: Removing the client’s peripheral IV is not related to the request for ice chips and is unnecessary unless there is a specific reason to do so.

D: Checking the client for bladder distention is not relevant to the request for ice chips and does not address the immediate concern of safe swallowing.

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Correct Answer is C

Explanation

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

Correct Answer is ["740"]

Explanation

Step 1: Convert 4 oz juice to mL. 4 oz × 30 mL per oz = 120 mL

Step 2: Convert 6 oz hot tea to mL. 6 oz × 30 mL per oz = 180 mL

Step 3: Ice chips are recorded at half their volume. 100 mL ÷ 2 = 50 mL

Step 4: IV bolus is already in mL. 150 mL

Step 5: Convert 8 oz broth to mL. 8 oz × 30 mL per oz = 240 mL

Step 6: Add all the volumes together. 120 mL + 180 mL + 50 mL + 150 mL + 240 mL = 740 mL

The nurse should record 740 mL of intake on the client’s record.

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A nurse is caring for a client who is postoperative and has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

A nurse is completing an 8-hour I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client’s record?

Correct Answer is ["740"]

Explanation

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