Nokea
A client with Crohn's disease is receiving parenteral nutrition. Which of the following interventions should the nurse not include in the care of this client?
- A. Remove the parenteral nutrition solution from the refrigerator 2 hours before infusion.
- B. Remove unused parenteral nutrition after 12 hours of use.
- C. Monitor daily laboratory values and report abnormalities as needed.
- D. Monitor the flow rate of the parenteral nutrition carefully and adjust it if necessary.
Correct Answer: B
Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.
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A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?
- A. A client with a weight of 128 lb and height of 70 inches
- B. A client with a weight of 150 lb and height of 68 inches
- C. A client with a weight of 200 lb and height of 72 inches
- D. A client with a weight of 133 lb and height of 60 inches
Correct Answer: A
Rationale: To determine a healthy BMI, we need to calculate it using the formula: BMI = weight (lbs) / height^2 (inches) x 703. For choice A, BMI = 128 / (70 x 70) x 703 = 18.38, which falls within the healthy BMI range of 18.5-24.9. Therefore, choice A is correct. Choices B, C, and D have BMIs of 22.8, 27.1, and 26.1, respectively, which are outside the healthy range. Thus, choices B, C, and D are incorrect.
A nurse is planning to teach a client about a low-potassium diet. Which of the following foods should the nurse instruct the client to avoid?
- A. Butter
- B. Poultry
- C. Yogurt
- D. Orange juice
Correct Answer: D
Rationale: Orange juice is high in potassium and should be avoided in a low-potassium diet. Butter, poultry, and yogurt are low-potassium food choices and can be included in a low-potassium diet. Poultry is a good source of lean protein, yogurt is a good source of calcium and protein, and butter is low in potassium. Therefore, the nurse should instruct the client to avoid orange juice as it is high in potassium, which is not suitable for a low-potassium diet.
A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?
- A. This is a normal, expected reaction for a child of this age.
- B. This is a response to an overstimulating environment.
- C. This is a common reaction to an overexposure to caregivers.
- D. This is a typical reaction for a child who is sick.
Correct Answer: A
Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.
A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?
- A. NPO until dysphagia subsides
- B. Supplements via nasogastric tube
- C. Initiation of total parenteral nutrition
- D. Soft residue diet
Correct Answer: B
Rationale: In the scenario of severe dysphagia following a CVA, the client may have difficulty swallowing and require alternative nutritional support. Providing supplements via a nasogastric tube allows for the delivery of essential nutrients directly into the stomach, bypassing the swallowing difficulties. NPO (nothing by mouth) until dysphagia subsides may be too restrictive for the client's nutritional needs. Initiation of total parenteral nutrition is usually reserved for cases where enteral feeding is not possible or contraindicated. A soft residue diet may not be suitable for a client experiencing severe dysphagia.
A client with a history of pancreatitis is being taught by a nurse. Which of the following food choices should the nurse instruct the client to avoid?
- A. Noodles
- B. Vegetable Soup
- C. Baked Fish
- D. Cheddar cheese
Correct Answer: D
Rationale: Patients with pancreatitis should avoid high-fat foods like cheddar cheese as they can exacerbate symptoms due to the organ's role in fat digestion. Noodles, vegetable soup, and baked fish are generally considered to be lower in fat content and are thus safer choices for individuals with pancreatitis.