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The nurse is caring for a client with hypovolemia related to prolonged vomiting and decreased intake of oral fluids. What activity(ies) should the nurse include in the client's plan of care? Select all that apply.
- A. Encourage the client to drink a 16 oz (480 mL) glass of water over the course of 15 minutes.
- B. Instruct the client to avoid beverages with additives such as electrolytes.
- C. Inform the primary provider if urine output is 3.5 oz (100 mL) per day or lower.
- D. Monitor weight daily.
- E. Assess skin turgor and mucous membranes.
Correct Answer: D,E
Rationale: The nurse should monitor the client's weight daily and assess skin turgor and mucous membranes. The nurse should offer clear liquids in small amounts. Slow introduction of fluids enables the client to develop tolerance and determine if it is possible to advance the diet. The nurse should recommend the use of commercial, over-the-counter beverages that contain electrolytes. If the client's urine output drops below 17 oz (500 mL) per day, the nurse should notify the primary provider because this indicates severe dehydration and the need for IV replacement fluids.
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A nurse is providing discharge teaching for a client following Roux-En-Y (RYGB) surgery. What instruction(s) should the nurse include in the teaching? Select all that apply.
- A. Stop eating when you feel full.
- B. Avoid all sweets.
- C. Choose breads, cereals, and grains that provide less than 2 g of fiber per serving.
- D. Limit mealtimes to fewer than 45 minutes.
- E. Begin with five to six meals a day.
Correct Answer: A,B,C
Rationale: The nurse should instruct the client to stop eating when the client feels full, avoid all sweets, and choose breads, cereals, and grains that provide less than 2 g of fiber per serving. The client should plan to take an hour to eat, chewing food slowly and thoroughly. The client should not begin with five to six meals a day but should instead gradually progress to this number of meals.
A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?
- A. I will eat two large meals a day, instead of three.
- B. I will eliminate bothersome foods from my diet.
- C. I will plan to sleep flat without pillows.
- D. I will start taking a nap after meals, when possible.
Correct Answer: B
Rationale: Irritating foods such as spices, caffeine, and alcohol should be avoided because doing so will assist in decreasing gastric acidity. Eating smaller meals is recommended to avoid lower pressure in the lower esophageal sphincter. Gastric reflux of acid is more likely to occur with positioning flat and lying down after a meal, so this should be avoided.
The nurse is teaching a client with a family history of oral cancer about the early stage of the disease. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. The early stage of oral cancer is characteristically asymptomatic.
- B. A lesion, lump, or other abnormality may be present on the lips or mouth.
- C. Difficulty eating or tasting food may occur.
- D. Pain and numbness are typically present.
- E. Persistent hoarseness is a hallmark sign.
Correct Answer: A,B
Rationale: The nurse should inform the client that oral cancer is characteristically asymptomatic in its early stage, though lesions, lumps, or other abnormalities may be present on the lips and mouth. While it is true that oral cancer may cause difficulty eating or tasting food, pain and numbness, and persistent hoarseness, these events occur later in the disease's progression and are not relevant in discussion of the early stage.
The nurse is caring for a client with oral cancer who reports severe mouth sensitivity. The client asks the nurse what might be done about the condition. What should the nurse include in the response?
- A. I can arrange a nutritional consultation.
- B. Cold liquids may help soothe the sensitivity.
- C. An anesthetic mouthwash may be used, but I will need to consult with the primary provider.
- D. A special diet may be necessary based on your ability to chew and swallow.
- E. Your doctor may prescribe a systemic analgesic for pain relief if necessary.
Correct Answer: A,C,D,E
Rationale: When responding to a client reporting severe mouth sensitivity due to oral cancer, the nurse should inform the client of possible options for managing the sensitivity. These include nutritional consultations, the use of anesthetic mouthwash if approved by the primary provider, the formulation of a special diet around the client's ability to chew and swallow, and a systemic analgesic for pain relief if the provider deems it necessary. It is inaccurate for the nurse to respond that cold liquids may soothe the sensitivity, because cold and hot liquids may increase the discomfort of sensitive oral tissues.
The nurse is caring for a client with anorexia and constipation due to reduced bulk in the diet and the use of liquid supplements. Which intervention(s) should the nurse include in the plan of care for the client? Select all that apply.
- A. Keep a record of the client's bowel movements.
- B. Consult with the health care provider and dietitian about changing the type of supplement.
- C. Dilute the formula until the client adjusts to the concentrated contents.
- D. Administer a prescribed stool softener.
- E. Assist the client and dietitian to decrease dietary fiber.
Correct Answer: A,B,C,D
Rationale: The nurse should keep a record of the client's bowel movements, consult with the health care provider and dietitian about changing the type of supplement, dilute the formula until the client adjusts to the concentrated contents, and administer a prescribed stool softener. Dietary fiber should be increased, not decreased, as a decrease will further reduce the amount of bulk in the client's diet and contribute to further constipation.