A nurse is completing the 8-hr 1&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer and Explanation

The Correct Answer is ["890"]

Answer= 890 ml

To calculate the total intake, we need to convert all the volumes to a common unit, such as milliliters (mL).

Clear soda: 4 oz = 120 mL (1 oz = 30 mL)
Toast: Assuming 1 slice of toast is approximately 50 mL.
Water: 12 oz = 360 mL (1 oz = 30 mL)
Fruit-flavored gelatin: 1 cup = 240 mL
Chicken broth: 1/2 cup = 120 mL

Now, add up all the intakes:

120 mL + 50 mL + 360 mL + 240 mL + 120 mL = 890 mL

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Correct Answer is ["A","B","E"]

Explanation

A. The opening of the pouch should be cut about 1/8 of an inch larger than the stoma to ensure a proper fit without restricting blood flow or irritating the stoma.

B. Placing a gauze over the stoma during a pouch change helps to absorb any discharge and keep the area clean while preparing the new appliance.

C. Povidone-iodine should not be used to clean around the stoma, as it can irritate the skin. The skin should be cleaned with mild soap and water or a recommended stoma cleanser.

D. A stoma that turns purple-blue is a sign of impaired blood flow and requires immediate medical attention. A healthy stoma should appear pink or red and moist.

E. The ostomy pouch should be emptied when it is about one-third full to prevent leakage, odor, and unnecessary pressure on the stoma.

A. Kennet B. Frestat C. Dairy products D. Caffeinated beverage

Correct Answer is D

Explanation

A. "Kennet" is not a recognized food or beverage and is not known to cause bladder irritation. The question might include this as a distractor.
B. "Frestat" is also not a known food or beverage associated with bladder irritation and does not play a role in urinary incontinence management.
C. Dairy products generally do not cause bladder irritation. Although some individuals may experience sensitivity to dairy, it is not commonly associated with bladder irritation or incontinence.
D. Caffeinated beverages are known bladder irritants. Caffeine can increase urine production and stimulate bladder activity, leading to increased urgency and frequency, which can exacerbate urinary incontinence.

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Naxlex Comprehensive Predictor Exams

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

Correct Answer is D

Explanation

Mr. Jones injured his left shin 4 days ago. Upon removal of the dressing, the wound is noted to be red, no slough or drainage. Surrounding tissue is swollen and is painful to the touch. The wound measures 3cm by 5 cm. What phase of healing is the wound in?

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A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. No drainage is noted. The nurse would treat the area with which dressing to promote healing?

The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?