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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 teaching a group of clients who are at risk for heart disease about decreasing saturated fats in their diet. Which of the following fats should the nurse recommend the clients use when cooking?
- A. Palm oil
- B. Peanut oil
- C. Canola oil
- D. Stick margarine
Correct Answer: C
Rationale: Canola oil is lower in saturated fats compared to palm oil, peanut oil, and stick margarine, making it a healthier option for clients at risk for heart disease. Palm oil is high in saturated fats, peanut oil has a moderate amount of saturated fats, and stick margarine is also high in saturated fats and trans fats, which are not heart-healthy choices.
A nurse is planning care for a client who has ascites secondary to liver disease. Which of the following interventions should the nurse include in the plan of care?
- A. Reduce complex carbohydrates to 30% of total calories.
- B. Restrict protein intake to less than 0.8 g/kg/day.
- C. Decrease daily caloric intake by 20%.
- D. Limit sodium to 2000 mg or less per day.
Correct Answer: D
Rationale: The correct answer is to limit sodium to 2000 mg or less per day. Ascites, which is the abnormal accumulation of fluid in the abdominal cavity, is commonly associated with liver disease. Limiting sodium intake helps manage fluid retention by reducing the fluid accumulation in the abdomen. Choices A, B, and C are incorrect because reducing complex carbohydrates, restricting protein intake, or decreasing caloric intake are not the primary interventions for managing ascites in liver disease.
A nurse is providing teaching to an obese client who has gestational diabetes and is at 25 weeks of gestation. Which of the following statements made by the client indicates a need for further teaching?
- A. This does not mean that my baby will have this disease.
- B. This means that I will have diabetes for the rest of my life.
- C. If I feel dizzy, I should drink six ounces of a non-diet soda.
- D. Being obese might be one reason why I developed diabetes.
Correct Answer: B
Rationale: The statement 'This means that I will have diabetes for the rest of my life' indicates a need for further teaching. Gestational diabetes often resolves after pregnancy, although it does indicate a higher risk for developing type 2 diabetes in the future. The other choices are correct or provide appropriate information: A) Understanding that gestational diabetes does not mean the baby will have the disease is accurate. C) Advising to drink non-diet soda if feeling dizzy is incorrect and potentially harmful due to the sugar content. D) Recognizing that obesity can be a risk factor for developing diabetes is a valid statement.
A client is planning eating strategies with a nurse who has nausea from equilibrium imbalance. Which of the following strategies should the nurse recommend?
- A. Encourage the client to eat, even if nauseated.
- B. Provide low-fat carbohydrates with meals.
- C. Limit fluid intake between meals.
- D. Serve hot foods at mealtime.
Correct Answer: B
Rationale: The correct answer is B: Provide low-fat carbohydrates with meals. Low-fat carbohydrates are easier to digest and can help manage nausea without overloading the digestive system. Encouraging the client to eat even if nauseated (Choice A) may worsen their symptoms. Limiting fluid intake between meals (Choice C) may lead to dehydration, which can exacerbate nausea. Serving hot foods at mealtime (Choice D) may not necessarily address the underlying issue of equilibrium imbalance causing nausea.
A healthcare provider is assessing a client who has a stage III pressure ulcer that is healing poorly. The provider should identify that which of the following vitamin deficiencies increases the client's risk for delayed wound healing?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin E
- D. Vitamin B6
Correct Answer: A
Rationale: Corrected Rationale: Vitamin C deficiency can impair collagen synthesis and delay wound healing, making it crucial for recovery from pressure ulcers.
Incorrect Rationales:
- Vitamin D deficiency is associated with bone health, not specifically wound healing.
- Vitamin E deficiency can lead to neurological and immune system issues but is not directly linked to delayed wound healing.
- Vitamin B6 deficiency can cause skin rashes and neurological symptoms but is not a primary factor in delayed wound healing.