Nokea
A nurse is caring for four clients. The nurse should plan to administer total parenteral nutrition for which of the following clients?
- A. A client who is postoperative following a laminectomy and is receiving IV PCA
- B. A client who has dysphagia and does not recognize his family
- C. A client who has COPD and is going home with oxygen
- D. A client who has colon cancer and will undergo a hemicolectomy
Correct Answer: D
Rationale: Total parenteral nutrition (TPN) is essential for clients undergoing significant surgical procedures like a hemicolectomy to ensure they receive adequate nutrition when oral intake is not possible. Choices A, B, and C do not typically require TPN. Choice A is managing postoperative pain with IV PCA, choice B is likely to need alternative feeding methods due to dysphagia, and choice C is going home with oxygen for COPD management, which does not directly relate to the need for TPN.
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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 caring for a 30-month-old toddler and is preparing a nutritional snack. Which of the following foods is appropriate for the nurse to offer the toddler?
- A. Plain popcorn
- B. Grapes
- C. Raw carrots
- D. Cheese
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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 healthcare professional has just inserted an NG tube for a client who is to start enteral tube feedings. Which of the following actions should the healthcare professional take to verify tube placement?
- A. Measure the tube length.
- B. Obtain an abdominal x-ray.
- C. Flush the tube with 20 mL of water.
- D. Auscultate the client's lungs.
Correct Answer: B
Rationale: Obtaining an abdominal x-ray is the most accurate method to verify the correct placement of an NG tube. Measuring the tube length is not a reliable method to confirm placement as it may vary among individuals. Flushing the tube with water and auscultating the client's lungs are not definitive methods to ensure proper NG tube placement.
A caregiver is teaching a parent about recommended protein intake for a toddler. Which of the following food selections is equivalent to 1 oz of protein?
- A. 2 tbsp peanut butter
- B. ½ cup peas
- C. 1 slice of bread
- D. 1 scrambled egg
Correct Answer: D
Rationale: One scrambled egg is equivalent to 1 oz of protein, making it a suitable choice for a toddler's diet. A ½ cup of peas (choice B) does not provide 1 oz of protein but is still a good source of protein. 2 tbsp of peanut butter (choice A) contains more than 1 oz of protein. 1 slice of bread (choice C) typically provides less protein than 1 oz.