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A nurse is teaching an in-service about manifestations of hypoglycemia to a group of newly licensed nurses. Which of the following should the nurse include in the teaching?
- A. Blurred vision
- B. Vomiting
- C. Kussmaul respirations
- D. Bradycardia
Correct Answer: A
Rationale: Corrected Rationale: Blurred vision is a common symptom of hypoglycemia and should be included in the teaching. Other manifestations like vomiting, Kussmaul respirations, and bradycardia are not typically associated with hypoglycemia. Vomiting is more commonly seen in conditions like food poisoning or gastrointestinal issues. Kussmaul respirations are deep and rapid respirations seen in metabolic acidosis, not hypoglycemia. Bradycardia is usually not a manifestation of hypoglycemia; tachycardia is more commonly associated with low blood sugar levels.
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A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?
- A. Measure the client's gastric residual every 12 hours.
- B. Obtain the client's electrolyte levels every 4 hours.
- C. Keep the client's head elevated at 15° during feedings.
- D. Flush the client's tube with 30 mL of water every 4 hours.
Correct Answer: D
Rationale: Flushing the client's tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client's gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client's electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client's head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.
A nurse is providing nutritional education to a client who is obese. The nurse should include in the information that which of the following gastrointestinal disorders is commonly associated with obesity?
- A. Peptic ulcer disease
- B. Gastroesophageal reflux disease
- C. Celiac disease
- D. Crohn's disease
Correct Answer: B
Rationale: Gastroesophageal reflux disease (GERD) is commonly associated with obesity due to increased abdominal pressure and other factors. Peptic ulcer disease (Choice A) is not commonly associated with obesity. Celiac disease (Choice C) is an autoimmune disorder triggered by gluten consumption and is not directly linked to obesity. Crohn's disease (Choice D) is a type of inflammatory bowel disease and is not specifically associated with obesity.
A nurse in a long-term care facility is developing strategies to promote increased food intake for an older adult client. Which of the following interventions should the nurse implement?
- A. Offer sugar substitutes to increase the client's appetite.
- B. Provide opportunities to eat three large meals per day.
- C. Provide entertainment while the client is eating.
- D. Offer finger foods at mealtime.
Correct Answer: D
Rationale: The correct intervention for promoting increased food intake for an older adult client is to offer finger foods at mealtime. Finger foods are easier for older adults to manage, making eating less cumbersome and more enjoyable, which can help increase overall food intake. Providing sugar substitutes (Choice A) may not necessarily increase appetite and could have negative health effects. Eating three large meals per day (Choice B) may be overwhelming and not suitable for older adults who may prefer smaller, more frequent meals. While providing entertainment (Choice C) during meals can be beneficial in some cases, it may not directly contribute to increased food intake as effectively as offering finger foods.
A nurse is providing anticipatory guidance to a client who has Phenylketonuria (PKU) and is planning a pregnancy. Which of the following information should the nurse include in the discussion?
- A. Diet sodas should not be consumed more than two or three times a week.
- B. Serum bilirubin should be monitored once or twice a month during pregnancy.
- C. Breastfeeding will not prevent your baby from developing PKU.
- D. A low-protein diet should be followed for three months before conception.
Correct Answer: D
Rationale: A low-protein diet should be followed for three months before conception in individuals with PKU who are planning a pregnancy. This diet helps manage PKU by reducing phenylalanine levels, which is crucial for maternal and fetal health. Choices A, B, and C are incorrect. Choice A is not directly related to managing PKU, choice B focuses on a different aspect of care during pregnancy, and choice C is inaccurate as breastfeeding will not prevent a baby from developing PKU.
A nurse is assessing the nutritional status of an infant who is 6 months old. The infant weighed 2.7 kg at birth. Which of the following indicates to the nurse that the infant is within the expected range?
- A. 5.5 kg
- B. 6.4 kg
- C. 4.5 kg
- D. 3.6 kg
Correct Answer: B
Rationale: The correct answer is B, 6.4 kg. An infant's weight should approximately double by 6 months. In this case, starting from a birth weight of 2.7 kg, a weight of 6.4 kg at 6 months indicates normal growth. Choice A (5.5 kg) is below the expected range for a 6-month-old infant. Choices C (4.5 kg) and D (3.6 kg) are also below the expected weight gain, indicating inadequate growth.