Question

A nurse is calculating the 8-hr fluid intake for a client who is receiving IV fluids and a clear liquid diet. The client had 880 mL of dextrose 5% in water IV bolus, a 6 oz cup of tea, 4 oz of apple juice, 8 oz of water, 3 oz of flavored gelatin, and 6 oz of broth. What should the nurse document as the client's 8-hr fluid intake? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.)

Answer 1

Correct Answers:

1110

Rationale :

✅Calculation: IV = 880 mL, Tea 6 oz = 180 mL, Apple juice 4 oz = 120 mL, Water 8 oz = 240 mL, Gelatin 3 oz = 90 mL, Broth 6 oz = 180 mL → Total = 880 + 180 + 120 + 240 + 90 + 180 = 1110 mL ✅When calculating total fluid intake, convert all oral fluids from ounces to milliliters using the standard conversion (1 oz = 30 mL). ✅Include all IV fluids and clear liquid oral intakes. ✅This accurate measurement is vital for assessing hydration status and fluid balance, especially in clinical situations involving fluid therapy or output monitoring.

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Answer 2

Correct Answers:

"As long as your child appears healthy, no intervention is necessary"

Rationale :

🔹Toddlers often experience physiologic anorexia, where appetite decreases as growth rate slows. 🔹As long as the child maintains appropriate growth and activity levels, this phase is developmentally normal and doesn't require aggressive dietary interventions. 🔹The response validates the parent’s concern while providing reassurance and preventing unnecessary anxiety or overfeeding.

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Answer 3

Correct Answers:

"l will cut my nails so they are rounded at the corners?'

Rationale :

✅Clients with diabetes mellitus should cut nails straight across to prevent skin injury and ingrown toenails, which can lead to serious infections due to poor circulation and impaired wound healing. ✅Rounded nail edges can increase the risk of skin breakdown. ✅The client’s statement reflects a need for further teaching on diabetic foot care precautions.

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Answer 4

Correct Answers:

Choose a vein that is soft on palpation.

Rationale :

✅When selecting a site for peripheral IV insertion, the nurse should choose a soft, palpable vein that is elastic and without signs of inflammation or previous trauma. ✅Softness and rebound indicate that the vein is patent and suitable for cannulation. ✅Avoid hard, cord-like, or previously punctured veins, which increase risk for infiltration or phlebitis.

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Answer 5

Correct Answers:

20

Rationale :

✅Calculation: 800 mg/day ÷ 2 = 400 mg per dose; 400 mg ÷ 20 mg/mL = 20 mL per dose ✅To determine the volume to administer, divide the prescribed dose per administration (400 mg) by the concentration (20 mg/mL) of the oral suspension. ✅Accurate medication dosage is essential for therapeutic effectiveness and client safety, especially with drugs like carbamazepine, which have narrow therapeutic windows.

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Answer 6

Correct Answers:

Three-point

Rationale :

🔹The three-point gait is the most appropriate crutch gait for a client who can bear weight on only one leg. 🔹 In this gait, the client moves both crutches and the non-weight-bearing leg forward together, followed by the weight-bearing leg. 🔹This method allows mobility without placing weight on the affected leg, which is essential for safety and healing. 🔹It is commonly used in cases of fractures, post-operative leg surgery, or any condition restricting weight-bearing.

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Answer 7

Correct Answers:

Support the client in her personal decision

Rationale :

✅Respecting client autonomy is a fundamental ethical principle in nursing. ✅A competent client has the right to refuse treatment, even if it is life-saving. ✅The nurse's role is to provide support without judgment, ensure the client is making an informed decision, and continue delivering holistic care. ✅Encouraging or pushing for continued treatment can be perceived as coercive and may damage the therapeutic relationship.

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Answer 8

Correct Answers:

"l will cut my nails so they are rounded at the corners?'

Rationale :

✅This statement reflects a misunderstanding of diabetic foot care. ✅Clients with diabetes should cut their toenails straight across, not rounded at the corners, to prevent ingrown toenails, which can lead to infections and complications due to impaired circulation and healing. ✅Regular foot inspection, proper footwear, and hygiene are essential in preventing diabetic foot ulcers.

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Answer 9

Correct Answers:

"l will take off my antiembolic stockings before I go to bed."

Rationale :

✅Antiembolic stockings (TED hose) should typically remain on while the client is in bed unless otherwise directed, especially in the early postoperative period. ✅Removing them at night may reduce their effectiveness in promoting venous return and preventing deep vein thrombosis (DVT). ✅The stockings should only be removed during hygiene care or as ordered.

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Answer 10

Correct Answers:

Withhold the treatment

Rationale :

✅If a nurse believes a prescribed medication may be harmful to the client—even after consulting the provider—the nurse has a professional and legal duty to withhold the medication and advocate for the client’s safety. ✅The nurse should then escalate the concern, possibly to a supervisor or ethics committee, but must not administer a medication that they believe is unsafe.

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QLexNursing

2 : The parent of a toddler is concerned that his child has suddenly become disinterested in certain foods. Which of the following statements is the appropriate response by the nurse?

3 : A nurse is caring for a client who has diabetes mellitus. Which of the following statements by the client indicates a need for further teaching about diabetic foot care?

4 : A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following is an appropriate action for the nurse to take?

6 : A nurse is teaching a client who can bear weight on only one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct this client to use?

7 : A nurse is caring for a client who has been diagnosed with breast cancer. After months of treatment, the client refuses to undergo further radiation therapy. Which of the following actions by the nurse is appropriate?

8 : A nurse is caring for a client who has diabetes mellitus. Which of the following statements by the client indicates a need for further teaching about diabetic foot care?

9 : A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?

10 : A nurse is caring for a client who has a new prescription for a medication that she thinks may be harmful to the client. After seeking clarification from the provider, the nurse still feels that it is unsafe. Which of the following actions should the nurse take?