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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.
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A nurse is teaching a client about strategies to prevent constipation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Drinking four to five glasses of water per day will prevent constipation.
- B. I should consume mineral oil once per day.
- C. Eating foods high in fiber will make elimination easier.
- D. I can skip a meal if I feel bloated.
Correct Answer: C
Rationale: The correct answer is C. Eating foods high in fiber increases stool bulk and promotes easier elimination, thus preventing constipation. Choices A, B, and D are incorrect. Drinking water is important, but the emphasis should be on high-fiber foods. Mineral oil is not a recommended first-line treatment for constipation, and skipping meals can disrupt regular bowel movements, potentially leading to constipation.
During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?
- A. Discuss nutritional requirements with the client.
- B. Refer the client to a senior citizen center.
- C. Arrange for a home-delivered meal program.
- D. Perform a nutrition screening.
Correct Answer: D
Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.
A client who is experiencing dumping syndrome following gastric surgery is receiving education from a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should drink additional fluids with my meals.
- B. I should eat high-fiber snacks between meals.
- C. I should eat a protein source with each meal.
- D. I can have caffeinated beverages in small amounts.
Correct Answer: C
Rationale: The correct answer is C. Eating a protein source with each meal can help manage dumping syndrome by slowing gastric emptying and reducing symptoms. This choice is the most appropriate as it directly addresses a key dietary recommendation for dumping syndrome. Choices A, B, and D are incorrect because drinking additional fluids with meals, eating high-fiber snacks between meals, and consuming caffeinated beverages can exacerbate dumping syndrome symptoms by increasing gastric emptying and worsening the condition.
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.