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

740 mL

800 mL

900 mL

None

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:

Let’s calculate step by step:

Juice: 4 oz × 30 mL = 120 mL
Tea: 6 oz × 30 mL = 180 mL
Ice chips: 100 mL × 0.5 = 50 mL (since only half of the volume of ice is counted as fluid)
IV bolus: 150 mL
Broth: 8 oz × 30 mL = 240 mL

Now add them:
120 + 180 + 50 + 150 + 240 = 740 mL

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 B

Explanation

Choice A reason:

Assessing sputum characteristics is important in monitoring respiratory conditions but does not directly precede preparing a client for postural drainage. It assesses the infection or inflammation severity, providing valuable data for treatment but isn't the immediate preparatory step for drainage.

Choice B reason:

Assessing pulse and respirations is critical before starting postural drainage as it establishes the client’s baseline vital signs and ensures they can tolerate the procedure. Monitoring these vital signs throughout ensures safety and effectiveness of the procedure. Thus, it’s the essential first step.

Choice C reason:

Instructing on pursed-lip exhalation aids in managing respiratory conditions by promoting effective breathing patterns but is not the immediate first step before percussion and postural drainage. It serves more as a therapeutic breathing technique.

Choice D reason:

Auscultating lung fields identifies lung sounds and areas needing drainage but isn’t the initial action. While important for confirming indications and evaluating effectiveness, it follows baseline assessments like pulse and respirations.

A. Passage of flatus B. Request for a cup of tea and some toast C. Hypoactive bowel sounds in two quadrants D. Abdominal distention

Correct Answer is A

Explanation

Choice A reason:

The passage of flatus is a clear indication that the gastrointestinal (GI) tract is regaining its normal function after surgery. It suggests that bowel movement is occurring and that peristalsis is returning, which is a positive sign of GI recovery.

Choice B reason:

A request for tea and toast may indicate the client feels well enough to eat, but it does not provide direct evidence of returning peristalsis. Appetite can return before bowel function is fully restored.

Choice C reason:

Hypoactive bowel sounds in two quadrants indicate reduced bowel activity, not necessarily the return of normal peristalsis. Normal peristalsis would typically produce active bowel sounds.

Choice D reason:

Abdominal distention often signals that gas or fluid is trapped in the intestines, suggesting delayed bowel function rather than the return of peristalsis.

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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 preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which nursing action should the nurse complete first?

Correct Answer is B

Explanation

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Correct Answer is A

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