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A nurse is documenting a client’s fluid intake over the past 8 hours.
Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

2 cups of soup

1 quart of water

8 oz of ice chips

6 oz of tea

Answer and Explanation

The Correct Answer is C

Choice A rationale

A cup of soup is typically 240 mL, so 2 cups would be 480 mL, which is more than 120 mL1.

Choice B rationale

A quart is a unit of volume equal to 946 mL, which is significantly more than 120 mL1.

Choice C rationale

8 oz of ice chips is approximately equivalent to 120 mL2. This is because when ice melts, it reduces in volume by about half, so 8 oz of ice chips would melt to about 4 oz of water, which is approximately 120 mL2.

Choice D rationale

6 oz is approximately 177 mL, which is more than 120 mL2.

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Correct Answer is D

Explanation

Choice A rationale

While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.

Choice B rationale

If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.

Choice C rationale

Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.

Choice D rationale

Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.

A. The route of administration B. The dosage of the medication C. The frequency of administration D. The name of the medication .

Correct Answer is B

Explanation

Choice A rationale

The route of administration, “by mouth”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice B rationale

The dosage of the medication, “0.25”, is not specified in terms of units (e.g., milligrams, micrograms). This could lead to errors in medication administration. Therefore, the nurse should confirm the dosage of the medication with the healthcare provider.

Choice C rationale

The frequency of administration, “daily”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice D rationale

The name of the medication, “digoxin”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

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A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who needs a nasogastric (NG) tube for stomach decompression. Which of the following steps should the nurse take when inserting the NG tube?

Correct Answer is D

Explanation

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Correct Answer is B

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A nurse is documenting a client’s fluid intake over the past 8 hours.
Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?