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A nurse is caring for a client who has a body mass index (BMI) of 30. Four weeks after nutritional counseling, which of the following evaluation findings indicates the plan of care was followed?
- A. BMI of 25
- B. Weight gain of 1.8 kg
- C. BMI of 33
- D. Weight loss of 2.7 kg
Correct Answer: D
Rationale: A weight loss of 2.7 kg in four weeks indicates effective adherence to a nutritional plan aimed at reducing body mass index (BMI), moving towards a healthier weight. Choices A, B, and C are incorrect because a decrease in weight, as shown in choice D, is the desired outcome when managing a client with a BMI of 30 to reach a healthier range.
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A client with hypertension is being educated by a nurse about a heart-healthy diet. Which of the following statements indicates that the client understands the teaching?
- A. I will get 15% of my total daily calories from saturated fats.
- B. I will decrease the potassium in my diet.
- C. I will limit my daily sodium intake to 3 grams.
- D. I will eat five 8-ounce servings of fruit daily.
Correct Answer: C
Rationale: The correct answer is C. Limiting daily sodium intake to 3 grams is crucial in managing blood pressure and is a fundamental aspect of a heart-healthy diet. High sodium intake can contribute to hypertension and cardiovascular issues. Choices A, B, and D are incorrect because getting 15% of daily calories from saturated fats, decreasing potassium intake, and eating five servings of fruit do not directly address the management of hypertension through sodium restriction.
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.
A client who is breastfeeding is being taught diet modification by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should drink an 8-ounce glass of water each time my baby nurses.
- B. I should take a 1500-milligram iron supplement daily.
- C. I can eat a 2500-calorie daily diet to lose 1 lb per week.
- D. I can eat ounces of swordfish daily.
Correct Answer: A
Rationale: The correct answer is A because drinking an 8-ounce glass of water each time the baby nurses helps maintain hydration and support milk production. Choice B is incorrect as the need for iron supplementation should be discussed with a healthcare provider. Choice C is incorrect as a 2500-calorie diet is not typically recommended for weight loss during breastfeeding. Choice D is incorrect as consuming high levels of swordfish is not advisable due to its mercury content, which can be harmful to the baby.
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.
A healthcare professional is reviewing the lab findings of a client who has Clostridium Difficile. Which of the following findings should indicate to the healthcare professional that the client is experiencing Fluid Volume Deficit?
- A. Hct 53%
- B. Potassium 3.5
- C. Sodium 145
- D. HbA1c 5
Correct Answer: A
Rationale: An elevated hematocrit level (Hct 53%) indicates hemoconcentration, a sign of fluid volume deficit. Hct measures the percentage of red blood cells in the blood and increases when there is a decrease in plasma volume, as seen in fluid volume deficit. Choices B, C, and D do not directly relate to fluid volume status. Potassium and sodium levels are more indicative of electrolyte imbalances, while HbA1c reflects average blood sugar levels over the past 2-3 months and is not specific to fluid volume status.