When calculating a client's 8 hour intake, how many mL of fluid should the practical nurse (PN) document? (Enter numeric value only.)
0730: 120 mL of orange juice, hard boiled egg, and toast
1130: 1 cup of broth, one-half sandwich, and 120 mL of apple juice
1400: voided 250 mL and consumed one 12-ounce can of soft drink
The Correct Answer is ["840"]
Convert each fluid intake into mL:
At 0730, the client consumed 120 mL of orange juice.
At 1130, the client consumed 1 cup of broth (1 cup = 240 mL) and 120 mL of apple juice.
At 1400, the client consumed a 12-ounce can of soft drink. Since 1 ounce = 30 mL, 12 ounces equals 360 mL.
Total fluid intake:
120 mL (orange juice)
240 mL (broth)
120 mL (apple juice)
360 mL (soft drink)
Add the total fluid intake:
120 mL + 240 mL + 120 mL + 360 mL = 840 mL
Answer: 840 mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.
Correct Answer is C
Explanation
A. Maintain sterile technique during specimen collection: Sterile technique is required for urine cultures, not for 24-hour urine collections. For a timed urine collection, clean collection techniques are sufficient to accurately measure excretion over a full day.
B. Assist the client to cleanse the perineal area prior to voiding: While perineal hygiene is important, it is not the primary step when starting a 24-hour urine collection. The critical action is ensuring that the first void is discarded to properly begin timing the collection period.
C. Instruct the client to discard the first voided specimen: The first void is discarded to ensure the collection accurately measures substances excreted during the full 24-hour period. Timing officially starts after discarding the initial urine, and every subsequent void must be collected.
D. Insert an indwelling urinary catheter: Inserting an indwelling catheter is unnecessary unless the client is unable to void independently. Most 24-hour urine collections are performed using normal voiding and collection into a clean container.
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