Nokea
A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?
- A. Check for gastric residual.
- B. Apply low intermittent suction.
- C. Increase the rate of the feeding.
- D. Request a higher-fat formula.
Correct Answer: A
Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.
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A nurse is reviewing the medication administration record for a client who is 2 days postoperative following abdominal surgery. The nurse should recognize that which of the following medications places the client at risk for wound dehiscence?
- A. Omeprazole
- B. Zolmitriptan
- C. Prednisone
- D. Verapamil
Correct Answer: C
Rationale: Corrected Rationale: Prednisone is a corticosteroid that can impair wound healing and increase the risk of wound dehiscence. Omeprazole (Choice A) is a proton pump inhibitor used to reduce stomach acid production and does not directly impact wound healing. Zolmitriptan (Choice B) is a medication used to treat migraines and does not affect wound healing. Verapamil (Choice D) is a calcium channel blocker used to treat high blood pressure and certain heart conditions, and it does not pose a significant risk for wound dehiscence.
A nurse is teaching a nutrition class for clients who have type 2 diabetes mellitus. Which of the following statements should the nurse include about management of acute illness?
- A. Consume carbs every 3-4 hrs
- B. Decrease fluid intake to 1000 mL per day
- C. Monitor blood glucose twice per day
- D. Check urine for ketones every 24 hrs
Correct Answer: A
Rationale: The correct statement is to 'Consume carbs every 3-4 hours.' During acute illness, it is important to maintain a consistent carbohydrate intake to help manage blood glucose levels for clients with type 2 diabetes. This frequent consumption can prevent hypoglycemia and provide energy needed during illness. Decreasing fluid intake (choice B) is not recommended during acute illness, as hydration is crucial to prevent complications. Monitoring blood glucose (choice C) more frequently than twice a day is necessary during acute illness. Checking urine for ketones (choice D) should be done more frequently than once every 24 hours during illness to monitor for diabetic ketoacidosis.
A client is following Seventh-Day Adventist dietary laws. Which of the following dietary guidelines should the nurse include in the plan of care?
- A. Replace salt with pepper when seasoning food.
- B. Request that coffee is removed from meal trays.
- C. Offer pork with two meals per week.
- D. Provide a high-protein snack between meals.
Correct Answer: B
Rationale: Seventh-Day Adventists typically avoid stimulants like caffeine, so requesting that coffee be removed from meal trays is appropriate. Choice A is incorrect because it does not specifically relate to Seventh-Day Adventist dietary guidelines. Choice C is incorrect as pork is generally avoided in Seventh-Day Adventist dietary laws. Choice D is incorrect as it does not address the specific dietary preferences of Seventh-Day Adventist clients.
A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to participate in developing a system of rewards.
- B. Arrange for someone to remain with the client for 30 minutes after meals.
- C. Offer the client a selection of beverages at each meal.
- D. Inform the client that a weight gain of 2.3 kg per week is expected.
Correct Answer: A
Rationale: Encouraging the client to participate in developing a system of rewards is an essential part of the plan of care for a client with anorexia nervosa. This action can help motivate and engage the client in their treatment plan, promoting a sense of achievement and progress. Choice B, arranging for someone to remain with the client for 30 minutes after meals, may not address the underlying issues related to anorexia nervosa and could potentially disrupt the client's independence. Choice C, offering a selection of beverages at each meal, is not directly related to addressing the client's condition of anorexia nervosa. Choice D, informing the client about an expected weight gain, could increase anxiety and may not be appropriate without considering the client's individual progress and readiness.
A nurse is providing discharge teaching about food choices to a client who has hypokalemia. Which of the following foods should the nurse identify as the best source of potassium?
- A. 1 cup grapes
- B. 1 cup shredded lettuce
- C. 1 cup cooked tomatoes
- D. 1 cup apple slices
Correct Answer: C
Rationale: Cooked tomatoes are high in potassium, which is crucial for maintaining normal cell function, nerve transmission, and muscle contraction, making them a suitable choice for addressing hypokalemia. Grapes, shredded lettuce, and apple slices do not contain as much potassium as cooked tomatoes, so they are not the best choice for addressing hypokalemia.