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 nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?
- A. Formula that remains in the bottle should not be used for one more feeding.
- B. Formula should be changed to whole milk when the infant is 12 months old.
- C. If the infant is gaining weight too rapidly, do not dilute the formula.
- D. If the infant turns away after taking most of the feeding, stop the feeding.
Correct Answer: D
Rationale: If the infant turns away after taking most of the feeding, it indicates they are full, and continuing to feed may lead to overfeeding. Choice A is incorrect because it is not safe to use formula that remains in the bottle for another feeding due to the risk of bacterial contamination. Choice B is incorrect as whole milk should be introduced after the infant is 12 months old, not 9 months old. Choice C is incorrect as diluting formula can compromise the infant's nutrition and should not be done without healthcare provider guidance.
A client is being taught by a nurse about adding more fiber to the diet. Which of the following foods has the highest fiber content?
- A. 1 cup cooked sweet potato
- B. 1 slice rye toast
- C. 1 cup raw watermelon
- D. 1 oz cashews
Correct Answer: D
Rationale: The correct answer is D, 1 oz of cashews. Cashews have a higher fiber content compared to sweet potato, rye toast, and watermelon. While sweet potatoes and rye toast contain fiber, cashews have a higher concentration, making them a better choice for increasing fiber intake. Watermelon, on the other hand, is low in fiber compared to the other options provided.
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.
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 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.