Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is completing the intake and output record for a preschool-age client admitted for fluid volume deficit.
The client has had the following intake and output during the shift:
Intake:
- 4 oz of Pedialyte
- 1/2 of an 8-oz cup of clear orange Jell-O
- 2 graham crackers
- 200 mL of D 5-1/2 sodium chloride IV
Output:
- 345 mL of urine
- 50 mL of loose stool
The nurse documents the client's intake as milliliters. How much liquidintake did the client have in Milliliters?
Round the answer to the nearest whole number.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
- To convert ounces to milliliters, multiply by 29.57
- 4 oz of Pedialyte = 118.28 mL
- 1/2 of an 8-oz cup of clear orange Jell-O = 118.28 mL
- 2 graham crackers = no liquid intake
- 200 mL of D 5-1/2 sodium chloride IV = 200 mL
- Total intake = 118.28 + 118.28 + 200 = 436.56 mL
- Round to the nearest whole number = 437 mL
- The nurse documents the client's intake as 437 mL
Similar Questions
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis.
Which of the following instructions should the nurse include in the teaching plan?
A. Include foods high in fiber.
While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.
B. Include foods high in starch and proteins.
Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.
C. Avoid foods high in fat.
This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.
D. Avoid foods high in sodium.
Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.
Full Explanation
Choice A reason:
While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.
Choice B reason:
Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.
Choice C reason:
This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.
Choice D reason:
Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.
A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?
A. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.
Removing the NG tube without further attempts to unclog it may not be necessary and could be an unnecessary intervention.
B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.
This statement is correct. Attempting to unclog the NG tube with warm water and an in-and-out motion is an appropriate next step.
C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers.
Flicking the tube with the fingers may not be effective in dislodging the clog, and it could potentially cause harm to the patient.
D. Withdraw the NG tube 3 to 5 cm and reattempt aspiration.
Withdrawing the tube 3 to 5 cm may not effectively address the clog and could potentially lead to complications.
Full Explanation
Choice A reason:
Removing the NG tube without further attempts to unclog it may not be necessary and could be an unnecessary intervention.
Choice B reason:
This statement is correct. Attempting to unclog the NG tube with warm water and an in-and-out motion is an appropriate next step.
Choice C reason:
Flicking the tube with the fingers may not be effective in dislodging the clog, and it could potentially cause harm to the patient.
Choice D reason:
Withdrawing the tube 3 to 5 cm may not effectively address the clog and could potentially lead to complications.
A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?
A. Assess for signs of infection.
While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.
B. Assess for a patent airway.
This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.
C. Assess ability to clear oral secretions.
Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.
D. Assess for ability to communicate.
Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.
Full Explanation
Choice A reason:
While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.
Choice B reason:
This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.
Choice C reason:
Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.
Choice D reason:
Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.