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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: Completing proper documentation of the medication error is important but should not be the first action. Immediate assessment of the patient is more critical.

B: Returning to the room to check and assess the patient is the first priority. The nurse needs to determine if the patient has experienced any adverse effects from the medication error and provide appropriate care.

C: Administering the antidote to the patient immediately is only necessary if the medication given has a known antidote and the patient is showing signs of adverse effects. Assessment should come first.

D: Alerting the charge nurse that a medication error has occurred is important for reporting and follow-up but should follow the immediate assessment and care of the patient.

A. Pull the fire alarm. B. Extinguish the fire. C. Confine the fire. D. Rescue the clients.

Correct Answer is D,A,C,B

Explanation

A: Pulling the fire alarm is essential to alert others to the fire and initiate the emergency response. However, it should follow the immediate rescue of clients.

B: Extinguishing the fire is important but should be done after ensuring the safety of clients and confining the fire.

C: Confining the fire helps prevent it from spreading and should be done after pulling the fire alarm.

D: Rescuing the clients is the first priority to ensure their safety. Clients should be moved to a safe area away from the fire.

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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

The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication. Which action should the nurse complete first?

Correct Answer is B

Explanation

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps, placing them in the selected order of performance. Use all the steps.)

Correct Answer is D,A,C,B

Explanation

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