The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
- A. Blood urea nitrogen 50 mg/dl
- B. Hemoglobin of 10.3 g/dl
- C. Venous blood pH 7.30
- D. Serum potassium 6 mEq/L
Correct Answer: D
Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.
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A nurse at a provider's office is reinforcing teaching with a client who is being treated with chemotherapy and is losing weight. Which of the following instructions should the nurse give to increase the client's caloric intake? (Select one that doesn't apply).
- A. Top yogurt with granola.
- B. Use honey on toast.
- C. Use milk instead of water in recipes.
- D. Increase fluids during meals.
Correct Answer: D
Rationale: Increasing fluids during meals does not directly contribute to increasing caloric intake. Topping yogurt with granola, using honey on toast, and using milk instead of water in recipes are effective ways to boost caloric intake. While adequate fluid intake is important for hydration and overall health, it does not address the specific need to increase caloric intake in this scenario.
A nurse is reinforcing teaching with a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? Select one that doesn't apply.
- A. Kidney beans
- B. Strawberries
- C. Peanut butter
- D. Whole wheat bread
Correct Answer: C
Rationale: The correct answer is C, Peanut butter. While kidney beans, strawberries, and whole wheat bread are high-fiber foods that help alleviate constipation, peanut butter is not a significant source of fiber. Peanut butter is more known for its protein and healthy fats content rather than being a good source of dietary fiber. Therefore, it should not be included as a primary recommendation for a high-fiber diet in the context of addressing constipation.
A client underwent coronary artery bypass grafting and is learning about following a low-cholesterol diet. Which of the following food choices indicates the client's understanding of these dietary instructions?
- A. Liver
- B. Milk
- C. Beans
- D. Eggs
Correct Answer: C
Rationale: The correct answer is C: Beans. Beans are an excellent choice for individuals following a low-cholesterol diet post-coronary artery bypass grafting due to their low cholesterol content. Beans are high in fiber and protein, making them a heart-healthy option. Choice A, Liver, is high in cholesterol and should be avoided in a low-cholesterol diet. Choice B, Milk, contains cholesterol and saturated fats, which are not ideal for this diet. Choice D, Eggs, are also high in cholesterol and should be limited in a low-cholesterol diet.
A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?
- A. Why don't you switch to formula to ensure your baby is eating enough?
- B. It is common for new mothers to worry that they are not producing enough milk for their baby.
- C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
- D. Your newborn will need to remain in the hospital so his weight can be monitored.
Correct Answer: C
Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.
A healthcare professional is assisting with the development of an education program about nutritional risk among adolescents to a group of parents of adolescents. Which of the following information should the healthcare professional include in the teaching? (Select all that apply).
- A. Skipping more than three meals per week
- B. Eating fast food once a week
- C. Hearty appetite
- D. Drink whole milk to ensure adequate calcium intake.
Correct Answer: A
Rationale: Skipping more than three meals per week is an indicator of poor nutritional habits in adolescents. This can lead to inadequate nutrient intake and negatively impact growth and development. Choices B, C, and D are not directly associated with poor nutritional habits among adolescents. Eating fast food once a week may not necessarily indicate poor nutrition if the overall diet is balanced. Having a hearty appetite does not provide specific information about nutritional risk, as appetite can vary among individuals. While whole milk can be a source of calcium, it is not necessary to drink whole milk specifically to ensure adequate calcium intake, as there are other sources of calcium available.