A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Advise the client that too much fruit can irritate the colon.

Inform the client that oatmeal contains gluten.

Commend the client for selecting fat free milk.

Encourage the client to choose decaffeinated coffee.

Answer and Explanation

The Correct Answer is B

Choice A

Advising the client that too much fruit can irritate the colon is not the right choice. While it's true that excessive consumption of certain fruits can cause gastrointestinal discomfort, this information is not directly related to celiac disease or the selected meal.

Choice B

Informing the client that oatmeal contains gluten is the right choice. Celiac disease is an autoimmune disorder in which consuming gluten, a protein found in wheat, rye, and barley, triggers an immune response that damages the small intestine. Oatmeal itself is naturally gluten-free, but it is often processed in facilities that also process gluten-containing grains, which can lead to cross-contamination. Therefore, it's important for individuals with celiac disease to choose certified gluten-free oats to avoid adverse reactions.

Choice C

Commending the client for selecting fat-free milk is not the best choice. While choosing a healthier milk option is beneficial for overall health, it is not the most important action in this situation, considering the client's celiac disease.

Choice D reason;

Encouraging the client to choose decaffeinated coffee is not the right choice. The choice of caffeinated or decaffeinated coffee is a matter of preference and is not directly related to celiac disease or the potential for gluten exposure from the oatmeal.

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Correct Answer is A

Explanation

Choice A

Demonstrating correct measurement of the tube insertion length is the first priority. Inserting a nasogastric tube to the appropriate length is crucial for ensuring that the tube reaches the stomach and is not inserted too far. Incorrect insertion length can lead to complications, discomfort, or potential harm to the patient. Therefore, demonstrating and ensuring the correct measurement of the tube insertion length takes priority.:

Choice B

Reminding the nurse to apply lubricant to the tube before insertion is not first priority. Applying lubricant helps ease the insertion process, but it is not the most critical step to prioritize initially.

Choice C

Confirming that the nurse has auscultated the client's bowel sounds is not the first priority. Bowel sounds assessment is important to ensure proper placement, but this step can be done after ensuring the correct measurement of the insertion length.

Choice D

Elevating the head of the bed before the nurse inserts the tube is not the first priority: Elevating the head of the bed helps facilitate the passage of the tube into the stomach, but it is not the first priority in this context.

A. Canned cream of mushroom soup, tuna salad, and water. B. Bacon. lettuce, and tomato sandwich, grapes, and skim milk. C. Taco salad, refried beans, low fat ice cream and coffee. D. Chicken salad on toast, fruit-flavoured yogurt, and iced tea.

Correct Answer is B

Explanation

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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A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse observes a newly hired nurse who is preparing to insert a nasogastric tube. Which action by the charge nurse takes priority?

Correct Answer is A

Explanation

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]

Correct Answer is B

Explanation

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