A nurse is recording the intake and output (I&O) for a client.
The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits.
Which volume should the nurse record on the I&O?
The Correct Answer is ["660"]
Step 1: Convert all liquid intake to mL: 8 oz of milk = 8 oz × 30 mL/oz = 240 mL 10 oz of water = 10 oz × 30 mL/oz = 300 mL 4 oz of gelatin = 4 oz × 30 mL/oz = 120 mL
Step 2: Sum the liquid intake: Total intake = 240 mL + 300 mL + 120 mL = 660 mL
The nurse should record 660 mL on the I&O.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Verifying the bilirubin level of the tube contents is not a standard or reliable method for checking the placement of a feeding tube. Bilirubin is a bile pigment found in the liver and bile ducts, and its levels are not indicative of tube placement in the gastrointestinal tract.
Choice B rationale
Checking the pH level of gastric contents can help determine if the tube is in the stomach, but it is not the most reliable method. Gastric pH is typically acidic (1.5-3.5), but the pH can vary, and this method does not rule out respiratory placement or other incorrect placements.
Choice C rationale
Auscultating for air insufflation involves listening for the sound of air injected through the tube into the stomach. However, this method is not reliable as it does not confirm the exact location of the tube and can give false positives if the tube is in the esophagus or respiratory tract.
Choice D rationale
Requesting a chest x-ray is the most reliable method for verifying feeding tube placement. It provides a clear visual confirmation of the tube's location, ensuring it is correctly positioned in the stomach or small intestine and not in the respiratory tract or other incorrect locations.
Correct Answer is A
Explanation
Choice A rationale
Placing an identification tag on the outside of the client's shroud is essential for proper identification, especially in cases requiring an autopsy. This practice ensures that the deceased person is accurately identified throughout the process and helps prevent any mix-ups or misidentifications.
Choice B rationale
Asking the assistive personnel to document the client's time of death is incorrect as it is the nurse's responsibility to document the time of death accurately in the medical records, not the assistive personnel's duty.
Choice C rationale
Wearing sterile gloves when cleaning the client's body is not necessary. Standard precautions and the use of non-sterile gloves are sufficient for postmortem care unless there are specific reasons requiring sterility, which is uncommon.
Choice D rationale
Removing the client's dentures and giving them to the client's family is incorrect for an autopsy case. Dentures should be left in place to maintain the integrity of the body and to ensure that all personal effects are accurately documented and managed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.