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A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?
- A. Stabilize the tube with tape to the newborn's cheek.
- B. Remove supplemental oxygen during the feeding.
- C. Measure the stomach aspirate prior to the feeding.
- D. Place the newborn on their left side for 30 minutes after the feeding.
Correct Answer: C
Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn's cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.
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A nurse is providing teaching to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. Albumin in my urine is an indication of normal kidney function.
- B. I will keep my HbA1c at five percent.
- C. I will have ketones in my urine if my blood glucose is maintained at 190 milligrams per deciliter.
- D. I will keep my blood glucose levels between 200 and 212 milligrams per deciliter.
Correct Answer: B
Rationale: The correct answer is B. Maintaining an HbA1c level of 5 percent indicates good long-term blood glucose control and understanding of diabetes management. Choice A is incorrect because the presence of albumin in the urine (albuminuria) is actually an indication of kidney damage in diabetes. Choice C is incorrect as ketones in the urine are a sign of inadequate insulin and can occur when blood glucose levels are high, not at a specific level like 190 mg/dL. Choice D is also incorrect as the client should aim to keep blood glucose levels within a tighter range for better control, typically between 80-130 mg/dL before meals and less than 180 mg/dL after meals.
A healthcare provider is on a med-surg unit caring for a client who follows the dietary laws of Orthodox Judaism. Which of the following menu selections should the healthcare provider recommend for this client?
- A. Fried catfish
- B. Broiled shrimp
- C. Pork sausage
- D. Grilled vegetables
Correct Answer: D
Rationale: The correct answer is D: Grilled vegetables. Orthodox Judaism restricts the consumption of certain animals, including catfish, shrimp, and pork, making choices A, B, and C inappropriate for a client following these dietary laws. Grilled vegetables are a safe and suitable option that complies with Orthodox Jewish dietary guidelines.
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.
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.
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.