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[blank] t Uploading Image...	t Uploading Image...	t Uploading Image...	t R
1 t <p><font class="font-s">A nurse is completing the intake and output</font></p><p><font class="font-s">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: </font></p><p><font class="font-s">Intake:</font></p><p><font class="font-s">4 oz</font></p><p><font class="font-s">of cranberry juice,</font></p><p><font class="font-s">1 ⁄ 2 slices of toast, 8 o</font><font class="font-s">z</font></p><p><font class="font-s">of black decaffeinated coffee, tuna ﬁ</font><font class="font-s">sh sandwich,</font></p><p><font class="font-s">1⁄ fruit-</font><font class="font-s">ﬂavored gelatin, 1 cup of cream of </font></p><p><font class="font-s">mushroom soup, 6 o</font><font class="font-s">z. of 1</font><font class="font-s">%</font><font class="font-s">milk, 1</font><font class="font-s">6</font><font class="font-s">o</font><font class="font-s">z</font><font class="font-s"> of water</font></p><p> </p><p><font class="font-s">Output: 1,300 ml of urine.</font></p><p> </p><p><font class="font-s">How many milliliters should the nurse document as</font><font class="font-s"> the client’s intake?</font></p> Uploading Image...	t <p>Answer:1380</p><p>Rationale:There are 30ml in each ounce and</p><p>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.</p><p> </p><p> </p><p>Nursing process step:</p><p>Implementation</p><p>Client needs category:</p><p>Physiological integrity</p><p>Client needs subcategory:</p><p>Basic care and comfort</p><p> </p> Uploading Image...	t Uploading Image...	t R
2 t <p>A hospitalized client asks the nurse for “something for pain.</p><p>” What information is most important for the nurse to gather before administering the medication? Select all that apply</p><p> </p><p>1.Administration time of the last dose</p><p>2.Client’s pain level on a scale of 1 to 10</p><p>3.Type of medication the client has been taking</p><p>4.Beeper number of the client’s physician</p><p>5.Client’s most current height and weight</p><p>6.Effectiveness of prior dose of medication</p> Uploading Image...	t <p>Answer:</p><p>1, 2, 3,6 </p><p> </p><p>Rationale:The nurse needs to know when the last dose was administered. Some clients request pain medication earlier than is ordered by the physician.</p><p>Pain, the ﬁfth vital sign, should be assessed using a pain scale and documented in the nursing notes.</p><p>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</p><p>also an important nursing function when managing the client’s pain. Therefore, she should ask the client if the prior dose was helpful.</p><p> </p><p>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</p> Uploading Image...	t Uploading Image...	t R
3 t <p>A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:</p><p> </p><p>A. Cover the right eye with a sterile 4×4</p><p>B. Attempt to remove the metal with a cotton-tipped applicator</p><p>C. Flush the eye for 10 minutes with running water</p><p>D. Cover both eyes and transport the client to the ER</p> Uploading Image...	t <p>D</p><p> </p><p> </p><p>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.</p><p> </p> Uploading Image...	t Uploading Image...	t R
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