Intake Category
Client consumes the following: ice cream, jello, steak, potatoes and ice chips. What gets documented for fluid intake?Client consumes the following: ice cream, jello, steak, potatoes and ice chips. What gets documented for fluid intake?
ice cream, jello and ice chips
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed?
A. 0645 Tuesday
B. 0675 Tuesday
C. 0715 Tuesday
D. 0735 Tuesday
C. 0715 Tuesday
Identify 3 sources of output
Urine, emesis, stool, wound drainage, blood loss
Name the 5 steps in the nursing process
Assess, Diagnose, Plan, Implement, Evaluate
The client has a BP of 120/80. What is the top number of the BP called?
Systolic pressure
How many ml’s are in 1 teaspoon?
15
True of False
If the nurse administers 30ml’s of Milk of Magnesia to a client the nurse does not need to count this as intake since it is a medication.
False
The client voids for 325ml at 0700. Has a 50ml emesis at 1000, and a 400ml diarhea at 1200. What is the total output?
775ml
Obtain a client’s past medical history is what part of the nursing process?
Assess-you are gathering data
A 60 year old client has a pulse rate of 88. Is this within normal range?
Yes, 60-100 is considered normal for an adult
How many ml’s are in 1oz
30
A client is receiving IV fluids @ 100ml’s/ hour. It is time for you to document the intake for the last 8 hours. How much will you document for the IV fluids?
A.100ml’s
B.400ml’s
C.800ml’s
D.1800ml’s
C-800ml’s
Fluid from Surgical drains do not count as output.
False
Your client is admitted with acute abdominal pain. You administer pain medication to help alleviate the client’s pain. What part of the nursing process did you just carry out?
Implementation- You already assess to see they were having pain, developed a diagnosis of abdominal pain, planned for the client to have a decrease level in pain and implemented a measure to help you reach this goal
A 30 year old client has a respiratory rate of 28. Is this within normal range?
No, 12-20 is normal RR for an adult
Name 3 forms of intake
Oral, IV, Tube Feedings
A client is receiving tube feedings @ 80ml’s/hour, 30ml free water flushes every 4 hours and IV fluids @ 125ml/hr. What is the total intake for an 8 hour period?
1700ml’s
True or False
Blood loss counts as output.
True
You are caring for a client who underwent a hip replacement two days ago. You start developing your plan of care for the day and you educate the client on the fact you would like them to ambulate 10 feet with a wheeled walker by the end of your shift. What part of the nursing process are you in
Planning phase- This is where you set goals and desired outcomes
True or False
After you complete your client’s bed bath, you leave the client with 4 side rails up for safety.
False- 4 side rails up are considered a restraint
If a patient consumes 80ml’s of ice chips, how many ml’s of intake do we document?
40
How many ml’s of urine should a patient produce every hour?
30
In an 8 hour shift, a client voided 600ml. How many ml’s of urine is being produced every hour and does this meet the standard of what should be produced every hour?
75ml’s/hr and yes, the body should produce at least 30ml’s/hr
You set a goal with your client to ambulate 3 times during your shift. You review the nursing assistant charting and see the client ambulated 3 times. What part of the nursing process are you carrying out?
Evaluation- You are seeing if the client met the goal that was set
Name 1 thing you learned today that you did not know before you walked into class
Answer is up to you.