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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 B

Explanation

A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.

B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.

C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.

D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.

A. Passage of flatus B. Request for a cup of tea and some toast C. Hypoactive bowel sounds in two quadrants D. Abdominal distention

Correct Answer is A

Explanation

A: The passage of flatus is a clear indication that intestinal function is returning. It shows that the gastrointestinal tract is beginning to move gas through the intestines, which is a positive sign of recovery after abdominal surgery.

B: A request for a cup of tea and some toast indicates that the client is feeling better and has an appetite, but it does not specifically indicate the return of intestinal function.

C: Hypoactive bowel sounds in two quadrants suggest reduced intestinal activity, which is not a sign of returning intestinal function. Normal bowel sounds should be present in all quadrants.

D: Abdominal distention can indicate a buildup of gas or fluid in the intestines, which is not a sign of returning intestinal function. It may suggest an obstruction or other complications.

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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 in a client’s room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

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Correct Answer is A

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