A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range

Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]

Canned cream of mushroom soup, tuna salad, and water.

Bacon. lettuce, and tomato sandwich, grapes, and skim milk.

Taco salad, refried beans, low fat ice cream and coffee.

Chicken salad on toast, fruit-flavoured yogurt, and iced tea.

Answer and Explanation

The Correct Answer is B

Choice A

Canned cream of mushroom soup, tuna salad, and water is inappropriate. Canned soups and processed foods like canned cream soups can be high in sodium. Tuna salad might also have added salt.

Choice B
B. Bacon, lettuce, and tomato sandwich, grapes, and skim milk is the appropriate selection. A serum sodium level of 155 mEq/L (155 mmol/L) is higher than the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L), indicating hypernatremia or high blood sodium levels. In this case, it's important for the client to choose foods that are lower in sodium to help manage their sodium intake.

Choice C

Taco salad, refried beans, low-fat ice cream, and coffee is inappropriate. Taco salad can contain salty ingredients, and refried beans can also be high in sodium. Processed meats and sauces used in tacos can contribute to sodium intake.

Choice D

Chicken salad on toast, fruit-flavoured yogurt, and iced tea is inappropriate. Chicken salad and some breads might contain added salt. Fruit-flavoured yogurts can also have added sugars, and iced tea can vary in sodium content depending on how it's prepared.

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Correct Answer is A

Explanation

Choice A

Observing for abdominal distention is recommended. Gastric residual volume (GRV) is the amount of formula or food remaining in the stomach after a feeding through a gastric tube. A GRV of 325 mL is relatively high, and it's important to assess the client for signs of potential complications before contacting the healthcare provider. Observe for signs of abdominal distention, which could indicate that the stomach is not adequately emptying or that the feeding is not being tolerated well.

Choice B

Calculating 24-hour caloric intake is not recommended: While monitoring caloric intake is important for overall nutritional assessment, it does not address the immediate concern of a high GRV and the potential need for adjustment of the feeding rate or management.

Choice C

Measuring urinary output is not recommended: Urinary output is important to monitor for fluid balance, but it may not be directly related to the elevated GRV.

Choice D

Checking for body weight changes is not recommended: Monitoring body weight is essential for assessing nutritional status, but it may not provide immediate insights into the impact of the elevated GRV.

A. Describe the value of eating smaller portion sizes. B. Encourage a well-balanced diet and moderate exercise. C. Explore the reasons the client wants to lose weight. D. Determine if the client has a history of anorexia.

Correct Answer is B

Explanation

Choice A

Describing the value of eating smaller portion sizes is not appropriate. While portion control is important, this advice alone might not address the overall dietary quality and exercise component necessary for effective weight loss.

Choice B

Encouraging a well-balanced diet and moderate exercise is appropriate. This intervention focuses on promoting healthy and sustainable weight loss. A well-balanced diet helps ensure that the client is getting all the necessary nutrients while aiming for a calorie deficit for weight loss. Moderate exercise complements dietary changes and contributes to overall health and weight management.

Choice C

Exploring the reasons, the client wants to lose weight is inappropriate. While understanding the client's motivations is valuable, this doesn't directly provide guidance on how to achieve the goal of losing 10 pounds.

Choice D

Determining if the client has a history of anorexia is inappropriate. While assessing for eating disorders is important in general, assuming there's no indication of anorexia, the focus should be on providing guidance for safe and effective weight loss.

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A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. What assessment should the nurse complete before contacting the healthcare provider?

Correct Answer is A

Explanation

An adult woman with a body mass index (BMI) of 21 tells the nurse that she wants to lose 10 pounds (4.5 kg). Which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

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A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu? Reference Range

Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]