A nurse is documenting an 8-hour intake and output (I&O) record for a patient who consumed 4 oz of juice, 6 oz of tea, a 100 mL cup of soda, an IV bolus of 150 mL, and 8 oz of broth. How many mL of intake should the nurse record on the patient’s chart?

500 mL

600 mL

700 mL

800 mL

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Let’s go through the calculations step by step:

Step 1: Convert all the quantities to milliliters (mL), as the nurse needs to record the intake in mL. We know that 1 oz is approximately 29.5735 mL.

4 oz of juice = 4 × 29.5735 mL = 118.294 mL

6 oz of tea = 6 × 29.5735 mL = 177.861 mL 8 oz of broth = 8 × 29.5735 mL = 236.628 mL Step 2: Add all the quantities together:

118.294 mL (juice) + 177.861 mL (tea) + 100 mL (soda) + 150 mL (IV bolus) + 236.628 mL (broth) = 783.783 mL Step 3: Round off the total intake to the nearest whole number as required, which gives us 784 mL.

Therefore, the nurse should record 784 mL on the patient’s chart. However, this option is not available in the choices given. The closest option to this calculated value is 800 mL (Choice D).

Now, let’s discuss the rationales for each choice:

Choice A rationale:

500 mL would be an underestimate of the patient’s fluid intake. It does not account for all the fluids the patient consumed.

Choice B rationale:

600 mL, similar to Choice A, is an underestimate. It does not accurately represent the total volume of fluids the patient consumed. Choice C rationale:

700 mL is closer to the calculated intake but is still an underestimate. It does not fully account for all the fluids the patient consumed.

Choice D rationale:

800 mL is the closest option to the calculated intake of 784 mL. Although it’s slightly over the actual intake, it’s the best choice among the given options.

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Correct Answer is ["B","C"]

Explanation

Choice A rationale:

Instructing the client to soak his feet daily is not recommended for individuals with diabetes. Soaking the feet can increase the risk of foot problems, particularly if the person has nerve damage or poor blood flow. It can lead to dry and cracked skin, which can increase the risk of infection. Therefore, this intervention should not be included in the care plan.

Choice B rationale:

Assisting the client in developing an individualized meal plan is a crucial intervention for managing type 2 diabetes. Meal planning is the first step in healthy eating and is especially important for people with diabetes because food directly impacts blood glucose levels. An individualized meal plan considers the person’s goals, tastes, lifestyle, and any medicines they’re taking. Therefore, this intervention should be included in the care plan.

Choice C rationale:

Checking the client’s blood glucose level before meals and at bedtime is an essential part of managing diabetes. Regular monitoring of blood glucose levels can help track the effect of diabetes medicines, understand how diet and exercise affect blood glucose levels, and detect if blood glucose levels are high or low. Therefore, this intervention should be included in the care plan.

Choice D rationale:

Administering an extra dose of insulin if the client’s blood glucose level drops to 50 mg/dl is not recommended. If a person’s blood glucose level is already low, administering additional insulin can lead to an insulin overdose, which can be lifethreatening. Therefore, this intervention should not be included in the care plan.

A. The client’s family will also need to take medications to prevent infection. B. A typical course of treatment involves 6 to 9 months of consistent medication use. C. Medications will need to be taken for the rest of the client’s life, even if the client feels better. D. Medications will need to be taken until the Mantoux test is negative.

Correct Answer is B

Explanation

Choice A rationale:

While it’s important for the client’s family to be aware of the disease and take precautions, they do not necessarily need to take medications to prevent infection. Tuberculosis (TB) is a contagious disease, but it typically requires close and prolonged contact to spread. Family members should be tested for TB, and if they test positive, then treatment would be necessary.

Choice B rationale:

This is the correct answer. A typical course of treatment for TB involves 6 to 9 months of consistent medication use. This is because TB bacteria die very slowly, and medications need to be taken for several months to ensure that all the bacteria are killed. If treatment is stopped too soon, some bacteria may survive and become resistant to the drugs.

Choice C rationale:

It’s not accurate to say that medications will need to be taken for the rest of the client’s life. While TB treatment is lengthy, it does not continue indefinitely. Once the full course of treatment is completed and the disease is cured, further medication is not typically necessary.

Choice D rationale:

The Mantoux test, also known as the tuberculin skin test, is used to determine whether a person has TB infection. However, the test can remain positive for a long time, even after successful treatment. Therefore, medications should not be taken until the Mantoux test is negative. Instead, the duration of treatment is determined by the healthcare provider based on various factors, including the patient’s response to the medication.

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A nurse is documenting an 8-hour intake and output (I&O) record for a patient who consumed 4 oz of juice, 6 oz of tea, a 100 mL cup of soda, an IV bolus of 150 mL, and 8 oz of broth. How many mL of intake should the nurse record on the patient’s chart?

Nursing Test Bank

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