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 jello how many milliliters of fluid did the
Logo

Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. 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 JELLO�. How many milliliters of fluid did the patient ingest?

Correct answer: B

Rationale: To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO� (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO�) = 480 ml. Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids. Choice A, 440 ml, is incorrect as it does not account for the correct calculation. Choice C, 220 ml, is incorrect as it is significantly lower than the correct total. Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.

2. After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?

Correct answer: C

Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.

3. Why is padding on a restraint helpful?

Correct answer: A

Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.

4. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?

Correct answer: D

Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.

5. Which of these types of fluid output is not typically measured?

Correct answer: D

Rationale: The correct answer is 'urine.' Urine output is routinely measured to assess renal function and fluid balance. Choices A, B, and C are types of fluid output that are typically measured in a clinical setting. Chest tube drainage is monitored to evaluate drainage from the chest cavity, emesis refers to vomitus which can indicate gastrointestinal issues, and evaporative water from the respiratory tract is considered insensible loss and is not directly measured but estimated in overall fluid balance assessments.

Similar Questions

The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
Under what circumstances is the legal right to confidentiality of client information waived?
After securing the client's safety from a faulty electric bed, what should the nurse do next?
A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?
A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the health care provider, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses