A nurse is completing an 8-hr 1&0 record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of 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"]

4 oz juice → 120 mL
6 oz tea → 180 mL
100 mL ice chips → 50 mL (Ice chips are counted as half their volume when melted)
IV bolus → 150 mL
8 oz broth → 240 mL

Total intake:

120+180+50+150+240=740 mL120 + 180 + 50 + 150 + 240=740 mL

Correct answer: 740 mL

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Correct Answer is B

Explanation

A. Continuous output from the stoma. Ileostomies typically have continuous liquid output, which is expected.

B. Presence of blood in the stool: Blood in the stool can indicate stomal irritation, ulceration, or bleeding from the intestines, which requires immediate medical attention.

C. Malodorous stool. While foul-smelling stool can suggest an issue (e.g., infection), it is not necessarily an emergency.

D. Liquid consistency with hard stool particles. Ileostomy output is expected to be liquid, and occasional solid particles may occur if certain foods are not fully digested.

A. Parasites B. Bacteria C. Steatorrhea D. Blood

Correct Answer is D

Explanation

A. Parasites: Stool tests for parasites require ova and parasite (O&P) testing, not a guaiac test.

B. Bacteria: Detecting bacteria (e.g., C. difficile, Salmonella) requires a stool culture, not a guaiac test.

C. Steatorrhea: Fecal fat tests, not guaiac tests, detect steatorrhea (fat malabsorption).

D. Blood: The guaiac test (fecal occult blood test, FOBT) detects hidden blood in the stool, which may indicate colorectal cancer, ulcers, or gastrointestinal bleeding.

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A nurse is completing an 8-hr 1&0 record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of 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

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A nurse is completing an 8-hr 1&0 record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of 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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