A client is admitted with protein-calorie malnutrition and is receiving supplemental feedings through a naso-duodenal tube. Which assessment finding indicates that the client's nutritional status is improving?
Urine output 200 mL over the last 4 hours.
Decreasing serum albumin levels.
Weight gain of 0.75 kg in the last 2 days.
Sodium (Na) level 128 mEq/L.
The Correct Answer is C
Weight gain is a positive indicator of improved nutritional status. It suggests that the client is receiving adequate nutrition and their body is able to build up and retain weight. This is particularly important in the case of protein-calorie malnutrition, as it indicates that the client is receiving sufficient protein and calories to support their nutritional needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This finding suggests that the client may have experienced a hip fracture. The shorter leg can be a result of the fractured bone, causing a misalignment or displacement. The protruding bump on the side can be a sign of a dislocated or fractured hip joint. It is important to assess and confirm this suspicion through appropriate diagnostic measures, such as X-rays, to provide the necessary medical intervention and management.
Correct Answer is D
Explanation
Hip spica casts are typically used to immobilize the hip joint and are often used in the management of hip dysplasia or after surgery. These casts can cause restricted mobility and limit blood flow to the legs and feet, which can lead to complications such as swelling, decreased circulation, or pressure sores.
Checking capillary refill in the toes is a critical nursing intervention to assess for the presence of adequate circulation and blood flow to the affected limb. If capillary refill is slow or absent, it may indicate compromised circulation and require immediate intervention to prevent further complications.
Palpating a brachial pulse, assessing bilateral radial pulses, or auscultating the heart rate apically are not the priority nursing actions for an infant with a hip spica cast. While monitoring vital signs and circulation are important components of nursing care, the priority at this stage is to assess and manage the immediate postoperative needs of the patient, including monitoring for potential complications related to the hip spica cast.
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