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 A

Explanation

Choice A reason: This is the correct answer because auscultating the client's abdomen for bowel sounds is an assessment that can provide information about the client's bowel motility and function. The nurse should listen for at least 5 minutes in each quadrant and note the frequency, intensity, and quality of bowel sounds.

Choice B reason: This is not an appropriate action to take first because providing privacy with a set time to defecate is an intervention that can promote regular bowel elimination and prevent constipation. The nurse should perform this action after assessing the client's bowel sounds and other factors that may affect defecation, such as pain, medication, diet, and activity.

Choice C reason: This is not an appropriate action to take first because encouraging oral intake of fluids is an intervention that can soften stool and facilitate bowel movement. The nurse should perform this action after assessing the client's bowel sounds and fluid balance status.

Choice D reason: This is not an appropriate action to take first because administering a fiber-based laxative is an intervention that can increase bulk and stimulate peristalsis. The nurse should perform this action after assessing the client's bowel sounds and contraindications for laxatives, such as bowel obstruction, impaction, or perforation.

A. Offer oral fluids every 4 hours. B. Monitor pulse pressure every 6 hours. C. Check for neck vein distention. D. Limit oral fluids prior to bedtime.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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