A nurse is completing an 8-hour intake and output (I&O) record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

600 mL

700 mL

800 mL

900 mL

Answer and Explanation

The Correct Answer is B

Choice A reason:

Calculating the total intake includes converting ounces to milliliters and adding all fluid intakes. 4 oz juice equals 120 mL, 6 oz hot tea equals 180 mL, ice chips are counted as half their volume, so 100 mL ice chips equals 50 mL, 150 mL IV bolus, and 8 oz broth equals 240 mL. Adding these up: 120 + 180 + 50 + 150 + 240 = 740 mL. Choice A, 600 mL, underestimates the total intake, excluding necessary details in the calculation.

Choice B reason:

To record the correct intake, conversion of all quantities into milliliters is crucial: 4 oz juice (120 mL), 6 oz hot tea (180 mL), 100 mL ice chips (50 mL), 150 mL IV bolus, and 8 oz broth (240 mL), totaling 120 + 180 + 50 + 150 + 240 = 740 mL. 740 mL closely aligns with Choice B (700 mL). Slight discrepancy is due to rounding or estimate in practical settings, making Choice B the most accurate.

Choice C reason:

800 mL inaccurately inflates the total intake. Accurate calculation yields 740 mL as the total fluid intake, considering all conversions and additions. Choice C misrepresents this value.

Choice D reason:

900 mL is another overestimate. Proper conversion and summation of all fluids indicate the total intake is 740 mL. Choice D is significantly higher than this calculated total, demonstrating the importance of precise conversion and addition for accurate records.

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Correct Answer is C

Explanation

Choice A reason:

Placing the wheelchair on the client's left side is not helpful for someone with left homonymous hemianopsia, as the client will have difficulty seeing the left side. This intervention does not address the visual deficit properly.

Choice B reason:

Orienting the client to the food on the plate using the clock method is beneficial for clients with visual impairments, but it is not specific to addressing left homonymous hemianopsia. It does not help the client scan their environment effectively.

Choice C reason:

Teaching the client to turn their head to scan to the right helps compensate for the left-sided visual field loss. This strategy allows the client to detect objects in their blind spot and improves their ability to navigate their environment safely.

Choice D reason:

Placing the bedside table on the right side of the bed ensures it is within the client’s field of vision and easily accessible, which is a supportive measure. However, teaching scanning techniques is more critical in helping the client adjust to their visual deficit.

A. Reposition the client at least every 2 hours. B. Clean the wound with hydrogen peroxide solution. C. Massage reddened areas with dressing changes. D. Apply a heat lamp twice a day.

Correct Answer is A

Explanation

Choice A reason:

Repositioning the client at least every 2 hours is a standard intervention to prevent further pressure ulcers and promote healing of existing ones. This practice helps alleviate pressure on vulnerable areas, improving blood circulation and reducing the risk of tissue breakdown.

Choice B reason:

Cleaning the wound with hydrogen peroxide solution is not recommended for pressure ulcers as it can damage healthy tissue and delay wound healing. Alternative wound cleaning solutions that are less harsh should be used to promote a more conducive healing environment.

Choice C reason:

Massaging reddened areas with dressing changes is contraindicated as it can exacerbate tissue damage and increase the risk of further ulceration. Gentle handling and appropriate wound care are essential to prevent additional harm to the affected areas.

Choice D reason:

Applying a heat lamp twice a day is not a standard or recommended practice for treating pressure ulcers. Heat can increase the risk of burns and further tissue damage. Proper wound care, including maintaining a clean and moist wound environment, is more effective for healing.

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A nurse is completing an 8-hour intake and output (I&O) record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention for this client?

Correct Answer is C

Explanation

A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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