The nurse is completing the intake and output record for a preschool-age client admitted for fluid volume deficit.

The client has had the following intake and output during the shift:

Intake:

4 oz of Pedialyte

1/2 of an 8-oz cup of clear orange Jell-O

2 graham crackers

200 mL of D 5-1/2 sodium chloride IV

Output:

345 mL of urine

50 mL of loose stool

The nurse documents the client's intake as milliliters. How much liquidintake did the client have in Milliliters?
Round the answer to the nearest whole number.

Answer and Explanation

The Correct Answer is ["437"]

To convert ounces to milliliters, multiply by 29.57
4 oz of Pedialyte = 118.28 mL
1/2 of an 8-oz cup of clear orange Jell-O = 118.28 mL
2 graham crackers = no liquid intake
200 mL of D 5-1/2 sodium chloride IV = 200 mL
Total intake = 118.28 + 118.28 + 200 = 436.56 mL
Round to the nearest whole number = 437 mL
The nurse documents the client's intake as 437 mL

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Correct Answer is B

Explanation

Choice A reason:

Removing the NG tube without further attempts to unclog it may not be necessary and could be an unnecessary intervention.

Choice B reason:

This statement is correct. Attempting to unclog the NG tube with warm water and an in-and-out motion is an appropriate next step.

Choice C reason:

Flicking the tube with the fingers may not be effective in dislodging the clog, and it could potentially cause harm to the patient.

Choice D reason:

Withdrawing the tube 3 to 5 cm may not effectively address the clog and could potentially lead to complications.

A. Include foods high in fiber. B. Include foods high in starch and proteins. C. Avoid foods high in fat. D. Avoid foods high in sodium.

Correct Answer is C

Explanation

Choice A reason:

While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.

Choice B reason:

Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.

Choice C reason:

This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.

Choice D reason:

Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

Correct Answer is B

Explanation

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?

A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?

The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?