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 C

Explanation

A. Placing the client supine with knees bent helps reduce abdominal pressure, but it is not the first action. Protecting the exposed organs from infection or drying out takes priority.

B. Assessing for manifestations of shock is important, but the immediate concern is to prevent further injury or infection to the exposed tissues.

C. The priority action when a wound eviscerates is to cover the area with a sterile dressing moistened with 0.9% sodium chloride solution to keep the organs moist and prevent infection until surgical repair can be done.

D. Raising the head of the bed slightly may help reduce pressure, but it is not the most immediate action compared to covering the exposed organs to prevent drying or infection.

A. Stage 1 pressure ulcer B. Stage 4 pressure ulcer C. Stage 2 pressure ulcer D. Stage 3 pressure ulcer

Correct Answer is D

Explanation

A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.

B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.

C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.

D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Correct Answer is C

Explanation

The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Correct Answer is D

Explanation

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

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?

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.)