A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Encourage mouth care before and after meals.

Monitor the client for changes in mental status.

Assess the client's laboratory work for increased calcium levels.

Advise the client to keep a food diary.

Instruct the client to drink extra fluids between meals.

Answer and Explanation

Correct Answer : A,B,D,E

A. Encouraging mouth care before and after meals helps maintain oral hygiene, which is essential for appetite stimulation and preventing oral infections.

B. Monitoring the client for changes in mental status is important as malnutrition can lead to cognitive impairment and changes in mental status.

C. Assessing the client's laboratory work for increased calcium levels may not be directly related to malnutrition due to cancer. Elevated calcium levels are more commonly associated with conditions like hyperparathyroidism or certain cancers, but it's not typically a direct consequence of malnutrition.

D. Advising the client to keep a food diary helps track food intake, identify any patterns related to malnutrition, and guide dietary interventions.

E. Instructing the client to drink extra fluids between meals helps prevent dehydration, especially if the client's intake is compromised due to malnutrition or cancer-related treatments.

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Correct Answer is D

Explanation

A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.

B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.

C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.

D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.

A. 18% B. 44% C. 36% D. 54%

Correct Answer is D

Explanation

A. 18% is inaccurate

B. 44% is inaccurate

C. 36% is inaccurate

D. According to the Rule of Nines:

Each arm is typically assigned 9% (4.5% for each arm). The chest and abdomen together are assigned 18%.

The upper back is assigned 9%.

The lower back is assigned 9%.

Each leg is typically assigned 18% (9% for each leg). Adding these percentages together for the described burns:

9% (each arm) + 18% (chest and abdomen) + 9% (upper back) + 9% (lower back) = 54%

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A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?

Correct Answer is D

Explanation

A nurse is caring for a client who has burns on both arms, chest, abdomen and upper and lower back. Utilizing the Rule of Nines, the nurse estimates that the extent of the client's burns is which of the following percentages?

Correct Answer is D

Explanation

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