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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.
Choice B rationale
The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.
Choice C rationale
The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.
Choice D rationale
Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.
Correct Answer is A
Explanation
The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.
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