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 ["A","D","E"]
Explanation
Choice A rationale
Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.
Choice B rationale
Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.
Choice C rationale
A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.
Choice D rationale
Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.
Choice E rationale
Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.
Correct Answer is D
Explanation
Choice A rationale
Applying cornstarch powder to the perineal area can lead to clumping and skin irritation, especially in a moist environment. It is not recommended for managing fecal incontinence.
Choice B rationale
Turning the client every 4 hours is important for preventing pressure ulcers but does not directly address fecal incontinence. Frequent turning should be combined with other measures for skin protection.
Choice C rationale
Cleansing the perineal area with povidone-iodine solution can be harsh and drying to the skin. It is not typically recommended for routine care of fecal incontinence.
Choice D rationale
Placing a moisture barrier ointment over the perineal area protects the skin from irritation and breakdown caused by fecal matter. It creates a protective layer, which is essential in managing fecal incontinence.
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