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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?

Answer and Explanation

The Correct Answer is ["740"]

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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Correct Answer is D

Explanation

A: Blood pressure of 178/90 mm Hg indicates hypertension, not dehydration. Dehydration typically leads to low blood pressure due to reduced blood volume.

B: Jugular vein distention is associated with fluid overload or heart failure, not dehydration. Dehydration usually results in flat neck veins.

C: A heart rate of 50 beats per minute is bradycardia and is not typically associated with dehydration. Dehydration often causes an increased heart rate (tachycardia) as the body tries to maintain adequate circulation.

D: Skin tenting present is a classic sign of dehydration. When the skin is pinched and does not return to its normal position quickly, it indicates a lack of fluid in the tissues.

A. Provide the client with a diet high in protein. B. Reposition the client every 3 hours. C. Massage bony prominences to promote circulation. D. Apply cornstarch to keep the skin dry.

Correct Answer is A

Explanation

A: Providing the client with a diet high in protein is essential for maintaining skin integrity. Protein is crucial for tissue repair and regeneration, which helps prevent skin breakdown and promotes healing of existing wounds.

B: Repositioning the client every 3 hours is less effective than the recommended every 2 hours. Frequent repositioning helps to relieve pressure on vulnerable areas and prevent pressure injuries.

C: Massaging bony prominences is not recommended as it can cause further damage to already fragile skin and underlying tissues. Gentle handling and avoiding pressure on these areas are more appropriate.

D: Applying cornstarch to keep the skin dry is not advisable as it can lead to skin irritation and breakdown. Instead, using moisture-wicking products and maintaining proper skin hygiene are better practices.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

Correct Answer is D

Explanation

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Correct Answer is A

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