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A nurse is calculating the total fluid intake for a patient over a 4-hour period. The patient consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. How many mL of intake should the nurse record on the patient's chart? How many mL of fluid intake should the nurse record?
Correct Answer: 1160
Rationale: The correct answer is 1160 mL. To calculate this, first convert all measurements to mL: 1 cup = 240 mL, 1 oz = 30 mL.
Coffee (240 mL), orange juice (120 mL), water (90 mL), flavored gelatin (240 mL), tea (240 mL), broth (150 mL), water (90 mL).
Adding these up: 240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL.
Therefore, the nurse should record 1160 mL on the patient's chart.
Other choices are incorrect because they do not calculate the total accurately or convert all measurements to mL.
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A nurse is caring for a patient who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider? Which finding post-cholecystectomy should the nurse report?
- A. Clay-colored stools
- B. Mild abdominal pain
- C. Nausea
- D. Fatigue
Correct Answer: A
Rationale: Correct Answer: A: Clay-colored stools
Rationale: Clay-colored stools can indicate a potential issue with bile flow, which is crucial post-cholecystectomy. Absence of bile in the stool may suggest a blocked bile duct, leading to complications like jaundice or infection. This finding should be reported promptly for further evaluation and management.
Summary of other choices:
- B: Mild abdominal pain is common post-surgery and can be managed with pain medications.
- C: Nausea is also expected after surgery and can be managed with antiemetics.
- D: Fatigue is a common postoperative symptom and may improve with rest and proper nutrition.
A nurse is instructing a female client on how to collect a midstream urine sample. Which statement from the client indicates they understand the procedure?,Which statement indicates understanding of midstream urine sample collection?
- A. I will clean the inside of the container with a wipe.
- B. I will urinate a little then stop.
- C. I will use each cleansing wipe twice.
- D. I will use the cleansing wipe from front to back.
Correct Answer: B
Rationale: The correct answer is B. By urinating a little first and then stopping, the client can discard the initial stream that may contain contaminants from the urethra, ensuring a more accurate midstream sample. Cleaning the container with a wipe (A) does not pertain to the collection process. Using cleansing wipes twice (C) risks contamination. Using the wipe from front to back (D) is not relevant to urine sample collection.
A nurse is administering an oral medication to an older adult patient. The patient states, 'The pill I always take is green. I don't take an orange pill.' What should the nurse respond? What should the nurse respond to a pill color concern?
- A. This is the medication that your doctor wants you to take.
- B. Sometimes the same pill comes in a different color.
- C. I will check your medication order again.
- D. Let me explain the purpose of the medication.
Correct Answer: C
Rationale: The correct answer is C: I will check your medication order again. The nurse should respond this way because the patient is confused about the color of the pill, indicating a potential medication error. By checking the medication order again, the nurse can ensure that the patient receives the correct medication. Choice A does not address the patient's concern about the pill color. Choice B may confuse the patient further and does not address the potential error. Choice D is not relevant to the patient's immediate concern about the pill color.
Medical History (0700 hrs)
• Gestational age: 42 weeks
• Delivery: Spontaneous vaginal birth
• Amniotic fluid: Dark brown-greenish color noted
• Apgar scores: 8 at 1 minute, 9 at 5 minutes
Vital Signs (0700 hrs)
• Axillary temperature: 36.9°C (98.4°F)
• Heart rate: 170/min
• Respiratory rate: 72/min
• Birth weight: 4025 gm (8 lb 14 oz) (Appropriate for Gestational Age)
Nurses' Notes (0700 hrs)
The newborn was placed on the birth parent's abdomen immediately following delivery. The mouth and nose were suctioned with a bulb syringe to clear secretions. The newborn was dried and stimulated, resulting in a strong cry. The newborn was moving all extremities with a flexed tone noted. Acrocyanosis was present. The newborn was alert and active. Respirations were rapid and shallow with occasional expiratory grunting. Fine crackles were auscultated throughout the lung fields. A small amount of green- stained vernix was present in skin folds. The newborn had fingernails stained green. Molding of the skull and generalized soft occipital swelling were noted.
A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Exhibits After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.The condition that poses the greatest risk to the newborn is ---------------- due to -------------------
- A. Meconium aspiration syndrome
- B. Color of amniotic fluid
- C. Jaundice
- D. cold streets
- E. Birth Weight
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: A; Parameter to Monitor: C, E.
Rationale:
- Meconium aspiration syndrome (MAS) is the correct answer as newborns exposed to meconium in amniotic fluid are at risk for respiratory distress.
- The color of amniotic fluid (brown-green) indicates presence of meconium, which can lead to MAS.
- Monitoring jaundice (C) is important as newborns with MAS may develop complications affecting liver function.
- Monitoring birth weight (E) is crucial as MAS can impact the newborn's overall health and growth.
Summary of Incorrect Choices:
- Jaundice (C): Although important to monitor, it is not the greatest risk in this scenario.
- Cold stress (D): Not relevant to the information provided about the newborn.
- Birth weight (E): While important to monitor, it is not the greatest risk posed by the scenario.
A nurse is caring for a patient who is receiving IV fluids. The nurse notes that the IV site is red, warm, and painful. Which of the following actions should the nurse take first? What should the nurse do first for IV site issues?
- A. Slow the infusion rate.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: The correct action for the nurse to take first is to discontinue the IV line (choice C). This is essential to prevent further complications such as infection or infiltration. Discontinuing the IV line will stop the source of the redness, warmth, and pain at the IV site. Slowing the infusion rate (choice A) would not address the underlying issue and could potentially worsen the situation. Applying a warm compress (choice B) could also exacerbate the symptoms if there is an infection. Notifying the provider (choice D) is important but should come after the immediate action of discontinuing the IV line to address the IV site issues promptly.