A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?

Describe the food placement as though the plate were a clock.

Provide the client with small-handled adaptive utensils.

Discourage conversations during the client's mealtime.

Arrange for an assistive personnel to feed the client.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct answer because describing the food placement as though the plate were a clock can help the client locate and identify the food items on their tray. For example, the nurse can say, "Your chicken is at 12 o'clock, your mashed potatoes are at 3 o'clock, and your green beans are at 9 o'clock."

Choice B reason: This is not an appropriate action because providing the client with small-handled adaptive utensils can make it harder for them to grip and manipulate the utensils and increase their frustration and dependence. The nurse should provide the client with large-handled or weighted adaptive utensils that can improve their dexterity and control.

Choice C reason: This is not an appropriate action because discouraging conversations during the client's mealtime can make them feel isolated and depressed and reduce their appetite and enjoyment of food. The nurse should encourage conversations during the client's mealtime and provide social support and stimulation.

Choice D reason: This is not an appropriate action because arranging for an assistive personnel to feed the client can compromise their dignity and autonomy and increase their dependence and helplessness. The nurse should respect the client's preferences and abilities and provide assistance only when necessary.

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Correct Answer is C

Explanation

Choice A reason:

Offer oral fluids every 4 hours: This is incorrect because oral fluids should be offered more frequently to maintain hydration. Dehydrated patients need consistent fluid intake to prevent further fluid deficit.

Choice B reason:

Monitor pulse pressure every 6 hours: This is incorrect because pulse pressure monitoring is not a standard intervention for dehydration. Pulse pressure is more relevant for cardiovascular assessments rather than fluid status.

Choice C reason:

Check for neck vein distention: This is correct as it helps assess fluid overload, which can occur with IV fluid replacement. Jugular vein distention is a key indicator of fluid status and potential fluid overload.

Choice D reason:

Limit oral fluids prior to bedtime: This is incorrect as limiting fluids can worsen dehydration. Dehydrated patients need adequate fluid intake throughout the day.

A. Increased serum glucose levels B. Intermittent abdominal pain C. Absent bowel sounds D. Decreased calcium levels

Correct Answer is A

Explanation

Choice A reason: Increased serum glucose levels are a common complication of total parenteral nutrition (TPN), which is a form of intravenous feeding that provides high amounts of calories, proteins, and other nutrients. TPN can cause hyperglycemia, especially in clients who have stress, infection, or diabetes. The nurse should monitor the client's blood glucose levels regularly and adjust the infusion rate or insulin dosage as prescribed.

Choice B reason: Intermittent abdominal pain is not a typical complication of TPN, but it may indicate other problems such as bowel obstruction, perforation, or ischemia. The nurse should assess the client's abdomen for distension, tenderness, rigidity, or guarding and report any abnormal findings to the provider.

Choice C reason: Absent bowel sounds are not a direct complication of TPN, but they may indicate paralytic ileus, which is a temporary loss of bowel motility. Paralytic ileus can occur after surgery, trauma, or burns and can cause nausea, vomiting, constipation, or abdominal distension. The nurse should auscultate the client's bowel sounds every 4 hr and encourage early ambulation and oral intake as tolerated.

Choice D reason: Decreased calcium levels are not a common complication of TPN, but they may occur in clients who have hypoparathyroidism, renal failure, or malabsorption. Low calcium levels can cause muscle cramps, tetany, seizures, or cardiac arrhythmias. The nurse should monitor the client's serum calcium levels and administer calcium supplements as prescribed.

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A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?

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