Nokea
A patient is being cared for by a nurse who has stomatitis following radiation treatment. Which of the following is an appropriate intervention for the nurse to take?
- A. Serve foods without sauces or gravies
- B. Offer mouth rinses with normal saline and water
- C. Serve foods while still at a hot temperature
- D. Instruct the client to drink liquids without a straw
Correct Answer: B
Rationale: Offering mouth rinses with normal saline and water is an appropriate intervention for a nurse caring for a patient with stomatitis following radiation treatment. This intervention can help soothe and clean the mouth, promoting comfort and oral hygiene. Choice A is incorrect because serving foods without sauces or gravies does not directly address the client's stomatitis. Choice C is incorrect because serving hot foods can exacerbate discomfort in the client's mouth. Choice D is incorrect because using a straw can help in preventing further irritation in the client's mouth.
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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 nurse is caring for a client who is lactose intolerant. Which of the following clinical manifestations should the nurse assess?
- A. Fever
- B. Blood in stools
- C. Cramping
- D. Steatorrhea
Correct Answer: C
Rationale: The correct answer is C: Cramping. Cramping is a common clinical manifestation of lactose intolerance due to the inability to digest lactose properly. Fever (choice A) is not typically associated with lactose intolerance. Blood in stools (choice B) is more indicative of other gastrointestinal issues like inflammatory bowel disease. Steatorrhea (choice D) is the presence of excess fat in the stool and is not a typical symptom of lactose intolerance.
A client receiving chemotherapy treatments tells the nurse, 'I feel so nauseated after my treatments.' Which of the following instructions should the nurse provide the client?
- A. Eat common foods that are served cold.
- B. Sip fluids slowly throughout the day.
- C. Sit up for 1 hr after eating meals.
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D, 'All of the Above.' Common foods served cold, sipping fluids slowly throughout the day, and sitting up for 1 hr after eating meals can help manage nausea associated with chemotherapy. Eating common foods served cold can be easier on the stomach, sipping fluids slowly can prevent overwhelming the digestive system, and sitting up after meals can aid digestion. Choices A, B, and C all contribute to alleviating nausea and are appropriate instructions for the client.
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.
A nurse is teaching a group of clients who are at risk for heart disease about decreasing saturated fats in their diet. Which of the following fats should the nurse recommend the clients use when cooking?
- A. Palm oil
- B. Peanut oil
- C. Canola oil
- D. Stick margarine
Correct Answer: C
Rationale: Canola oil is lower in saturated fats compared to palm oil, peanut oil, and stick margarine, making it a healthier option for clients at risk for heart disease. Palm oil is high in saturated fats, peanut oil has a moderate amount of saturated fats, and stick margarine is also high in saturated fats and trans fats, which are not heart-healthy choices.