Nokea
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO®. How many milliliters of fluid did the patient ingest?
- A. 440 ml
- B. 480 ml
- C. 220 ml
- D. 660 ml
Correct Answer: B
Rationale: To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO® (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO®) = 480 ml. Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids. Choice A, 440 ml, is incorrect as it does not account for the correct calculation. Choice C, 220 ml, is incorrect as it is significantly lower than the correct total. Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.
You may also like to solve these questions
The nurse uses prioritization to determine all of the following except:
- A. time allotment for certain tasks.
- B. appropriate interventions.
- C. treatment procedures.
- D. the need for client education.
Correct Answer: C
Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.
The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 30 minutes if your NG residual is below 50 mL.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct Answer: A
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications. Therefore, the most appropriate response is to advise the client to lie down in 1 hour. Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes. Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness. Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.
What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and bandages
Correct Answer: V
Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (Choice A) may be beneficial in some cases, they are not universally as effective as repositioning. Topical medications (Choice C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (Choice D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.
A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:
- A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
- B. eat foods low in fat.
- C. empty his bladder prior to the procedure.
- D. assume the prone position.
Correct Answer: C
Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.
While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed's power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct Answer: A
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.