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3 Cards in this Set
- Front
- Back
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A nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for laboratory studies. The client has had the following intake and output during the shift: Intake: 4 oz of cranberry juice, 1 ⁄ 2 slices of toast, 8 oz of black decaffeinated coffee, tuna fish sandwich, 1⁄ fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz. of 1%milk, 16oz of water
Output: 1,300 ml of urine.
How many milliliters should the nurse document as the client’s intake? |
Answer:1380 Rationale:There are 30ml in each ounce and 240 ml in each cup. The fluid intake for this client includes 4 oz(120ml) of cranberry juice,8oz(240 ml) of coffee,1 ⁄ 2cup (120ml) of fruit-flavored gelatin, 1 cup (240 ml) of cream of mushroom soup,6 oz(180 ml) of milk, and 16oz (480 ml) of water,for a total of 1,380.
Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Basic care and comfort
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A hospitalized client asks the nurse for “something for pain. ” What information is most important for the nurse to gather before administering the medication? Select all that apply
1.Administration time of the last dose 2.Client’s pain level on a scale of 1 to 10 3.Type of medication the client has been taking 4.Beeper number of the client’s physician 5.Client’s most current height and weight 6.Effectiveness of prior dose of medication |
Answer: 1, 2, 3,6
Rationale:The nurse needs to know when the last dose was administered. Some clients request pain medication earlier than is ordered by the physician. Pain, the fifth vital sign, should be assessed using a pain scale and documented in the nursing notes. Whenever a pain medication is given. Pain is usually reassessed about 30 minutes after the medication is given. Physicians commonly order several different types of pain medication based on the client’s condition. It is important for the nurse to know which medication and which route was used to administer prior dosages. Evaluating the effectiveness of medications is also an important nursing function when managing the client’s pain. Therefore, she should ask the client if the prior dose was helpful.
Knowing the beeper number of the client’s physician is not as important as the other choices, although most nurses know the name of their clients’ physicians. Most medications aren’t ordered based on the client’s height, and weight. This information would have been obtained on admission |
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A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:
A. Cover the right eye with a sterile 4×4 B. Attempt to remove the metal with a cotton-tipped applicator C. Flush the eye for 10 minutes with running water D. Cover both eyes and transport the client to the ER |
D
The nurse should cover both of the client’s eyes and transport him immediately to the ER or the doctor’s office. Answers A, B, and D are incorrect because they increase the risk of further damage to the eye.
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