Calculate your patient's INTAKE and OUTPUT using the following information for your 1900-0700 shift.

Jevity (Tube feeding) 50 mL/hr, 6 oz. free water tube feeding flush, 2 units of PRBCs (250mL/each) of red blood cells, Zosyn IV 50 mL, 4 oz. ice chips, 0.9% NS 100 mL/hr. NG Suction: 50 mL, Urine: 1850 mL, Wound vac: 100 mL. (ANSWER INTAKE/OUTPUT)

Choice A rationale

Directly placing pills in a client's mouth with a gloved hand is generally not recommended as it can be perceived as invasive and may trigger the gag reflex, increasing the risk of aspiration. Client autonomy and active participation in medication administration are promoted for safety and adherence.

Choice B rationale

Tipping pills directly into a client's mouth can be problematic as it does not allow the client to assess the medication, potentially leading to discomfort or aspiration. It also bypasses the client's agency in the medication administration process, which is crucial for safety and compliance.

Choice C rationale

Offering the client the medication in their hand promotes autonomy and allows them to actively participate in the medication administration process. This approach respects client preferences, enhances safety by allowing self-administration, and facilitates the client's ability to examine the medication before ingestion, reducing the risk of errors.

Choice D rationale

Leaving medications unattended on a breakfast tray for later self-administration is a significant safety breach. This practice increases the risk of the medication being taken by another individual, loss or contamination, or incorrect timing of administration, potentially leading to adverse drug events. Direct observation of medication ingestion is essential.

Choice A rationale

Administering only 0.5 mL subcutaneously is a common volume for certain medications, but it is not the maximum. Larger volumes can sometimes be administered, depending on the site and medication characteristics, without causing undue tissue distention or discomfort.

Choice B rationale

The subcutaneous tissue layer has a limited capacity for fluid absorption, and volumes exceeding 1 mL can cause tissue distention, discomfort, and potentially impair absorption due to increased pressure. This volume minimizes local tissue irritation and ensures optimal medication uptake into the systemic circulation.

Choice C rationale

Administering 2 mL subcutaneously is generally discouraged due to the potential for significant tissue distention, discomfort, and pain. Such a large volume can also lead to poor absorption and increased risk of local adverse reactions, making it an impractical and often unsafe choice for routine subcutaneous injections.

Choice D rationale

While 1.5 mL is closer to the maximum, it often pushes the limits of comfortable and effective subcutaneous administration. This volume may cause considerable discomfort, particularly in clients with limited subcutaneous tissue, and can compromise absorption rates.