Nokea
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?
Correct Answer: 660 mL
Rationale: 8 oz milk (240 mL) + 10 oz water (300 mL) + 4 oz gelatin (120 mL) = 660 mL; only liquids are recorded.
You may also like to solve these questions
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.
A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?
- A. A client who has ulcerative colitis.
- B. A client who has cholecystitis.
- C. A client who uses laxatives.
- D. A client who has stomatitis.
Correct Answer: A
Rationale: Ulcerative colitis causes colon bleeding, leading to a positive test.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Unlock and remove the inner cannula.
- B. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- C. Scrub the inside and outside of the inner cannula with a small brush.
- D. Wipe the inside of the inner cannula with a folded pipe cleaner.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: B,A,C,D,E
Rationale: B: Prepare solution. A: Remove cannula. C: Scrub cannula. D: Wipe cannula. E: Cleanse stoma maintains sterility.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place the client's arms above her head prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the bed in the lowest position before logrolling the client.
- D. Place a pillow between the client's legs prior to logrolling.
Correct Answer: D
Rationale: A pillow maintains spinal alignment during logrolling post-laminectomy.