Nokea
A client reports having difficulty losing weight. Which of the following responses by the nurse is appropriate?
- A. Eat small portions of high-calorie foods first.
- B. Set a goal, and you will be able to attain it.
- C. It is helpful to self-monitor your eating.
- D. Taste food while cooking to help curb your appetite.
Correct Answer: C
Rationale: The correct answer is C: 'It is helpful to self-monitor your eating.' Self-monitoring dietary intake is an evidence-based strategy that enhances awareness and accountability, making it an effective approach for weight management. Choice A is incorrect as focusing on high-calorie foods first may not be the most effective strategy for weight loss. Choice B is too general and lacks actionable advice. Choice D, tasting food while cooking, does not directly address the client's difficulty in losing weight and is not a proven method for weight management.
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A client with anorexia undergoing radiation therapy is being taught by a nurse. Which instruction should the nurse include in the teaching?
- A. Limit high-calorie supplements to between meals
- B. Avoid overeating during your 'good' days
- C. Eat hot foods instead of cold foods
- D. Consume nutrient-dense foods first
Correct Answer: D
Rationale: The correct instruction for a client with anorexia undergoing radiation therapy is to consume nutrient-dense foods first. This ensures that the client receives the necessary calories and nutrients. Option A is incorrect because high-calorie supplements should not be limited but rather incorporated wisely into the diet. Option B is incorrect as overeating is not recommended regardless of the type of day. Option C is incorrect as there is no specific preference for hot foods over cold foods in managing anorexia during radiation therapy.
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 client with chronic kidney disease is being taught about dietary needs by a nurse. Which of the following foods should the nurse identify as being the lowest in phosphorus?
- A. Medium apple
- B. Bran cereal
- C. Scrambled eggs
- D. Ground turkey
Correct Answer: A
Rationale: The correct answer is A, a medium apple. Apples are a suitable option for clients with chronic kidney disease as they are low in phosphorus. Bran cereal (choice B), scrambled eggs (choice C), and ground turkey (choice D) are all higher in phosphorus content compared to apples, making them less ideal choices for individuals with chronic kidney disease.
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.
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.