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. An adolescent who has a cervical fracture and is in a halo brace B. A middle adult who has a fractured radius and an arm cast C. An older adult who has a hip fracture and is in Buck's traction D. A young adult who has a femur fracture and is in skeletal balanced suspension traction

Correct Answer is C

Explanation

A. Although the adolescent in a halo brace has some immobility, the greatest risk factors for skin breakdown involve areas where prolonged pressure is applied, and older adults are more vulnerable due to age-related skin changes.

B. A fractured radius and arm cast do not pose a significant risk for skin breakdown because the client can still mobilize and reposition themselves, reducing prolonged pressure.

C. An older adult with a hip fracture in Buck's traction is at greatest risk for skin breakdown due to immobility, pressure from the traction setup, and the reduced skin elasticity and healing capacity that come with age.

D. While skeletal balanced suspension traction poses some risk, a young adult typically has better skin integrity and mobility than an older adult, reducing the risk for skin breakdown.

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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

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?

Correct Answer is C

Explanation

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

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?

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

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor for pressure ulcer?

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 assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?