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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 JELLO0. How many milliliters of fluid did the patient ingest?
- A. $440 \mathrm{ml}$
- B. $480 \mathrm{ml}$
- C. $22 \mathrm{ml}$
- D. $660 \mathrm{ml$
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.
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The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
- A. Perform hand hygiene and don gloves.
- B. Pinch the lens over the pupil and remove.
- C. Place the lens in a sterile container with normal saline.
- D. Irrigate the eye with normal saline to loosen the lens.
- E. Instruct the client to look up when removing the lens.
Correct Answer: A,C,E
Rationale: A: Hand hygiene and gloves prevent infection. C: Normal saline keeps lenses moist if no lens solution is available. E: Looking up aids safe lens removal. B: Pinching over the pupil risks corneal abrasion. D: Irrigation could damage or lose the lens.
The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse's best action?
- A. Resume the urine collection and collect one additional voided specimen.
- B. Discard the urine collected and begin a new urine collection immediately.
- C. Complete the urine collection and send all urine collected to the laboratory.
- D. Dispose of the urine collected and reschedule the test to begin the next morning.
Correct Answer: B
Rationale: B: A discarded void invalidates the collection; restarting ensures accuracy. A: Adding a void causes inaccuracies. C: Missing a void compromises results. D: Rescheduling is unnecessary as the test can start anytime.
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Measuring intake and output assesses fluid balance, critical in enteral feeding to prevent dehydration or fluid overload due to hyperosmotic feedings.
Client room environments should include:
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
- E. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
Correct Answer: B
Rationale: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.
The hospitalized client is able to stand to use an electronic digital scale for obtaining the client's prescribed daily weight. Which nursing interventions best ensure that the client's daily weight is accurate? Select all that apply.
- A. Ask the client to wear supportive shoes before stepping on the scale
- B. Ensure that the scale is calibrated and “zeroed†before a weight is obtained
- C. Weigh the client by moving the sliding indicator until the scale balances
- D. Weigh the client at different times of the day and then average the weights
- E. Take the weight as soon as the client wakens in the morning and after voiding
Correct Answer: B,E
Rationale: B: Calibration ensures accuracy. E: Weighing post-voiding at the same time daily standardizes results. A: Shoes add weight. C: Sliding indicators are for balance scales. D: Averaging weights reduces accuracy.