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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 C

Explanation

A: Discreetly hiding the medication in the patient’s favorite gelatin is unethical and violates the patient’s right to informed consent. This approach undermines trust and can lead to further resistance or legal issues.

B: Agreeing with the patient’s decision and documenting it in the chart is important, but it should not be the first action. The nurse needs to understand the patient’s reasons for refusal before making any decisions or documentation.

C: Exploring with the patient the reasons for not wanting to take the medication is the appropriate first action. This approach allows the nurse to understand the patient’s concerns, address any misconceptions, and provide relevant information. It also respects the patient’s autonomy and promotes a collaborative approach to care.

D: Educating the patient about the importance of the medication is crucial, but it should follow the exploration of the patient’s reasons for refusal. Understanding the patient’s perspective first ensures that the education provided is relevant and addresses specific concerns.

A. Expect some swelling in the hands and feet. B. Take the medication at bedtime. C. Eat foods that contain plenty of potassium. D. Take aspirin if headaches develop.

Correct Answer is C

Explanation

A: Expecting some swelling in the hands and feet is incorrect. Furosemide is a diuretic used to reduce fluid buildup, so swelling should decrease, not increase.
B: Taking the medication at bedtime is not recommended because furosemide increases urine output, which can disrupt sleep. It is better to take it in the morning.
C: Eating foods that contain plenty of potassium is important because furosemide can cause potassium loss. Consuming potassium-rich foods helps maintain electrolyte balance and prevent hypokalemia.
D: Taking aspirin if headaches develop is not related to the use of furosemide. The nurse should address headache management separately and ensure the client understands the specific instructions for furosemide use.

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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?

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