A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following actions by the AP requires intervention?

Providing a ham and cheese sandwich to a client who follows a kosher diet

Giving peanut butter to a client who was prescribed a mechanical soft diet

Offering ginger ale to a client who is a member of the Mormon faith

Serving ice cream to a client who prescribed a full-liquid diet

Answer and Explanation

The Correct Answer is A

A. Providing a ham and cheese sandwich to a client who follows a kosher diet: Kosher dietary laws prohibit pork and require specific food preparation. Giving a ham sandwich directly violates the client’s religious dietary restrictions and requires immediate correction and staff education to respect cultural and religious practices.

B. Giving peanut butter to a client who was prescribed a mechanical soft diet: A mechanical soft diet includes foods that are easy to chew and swallow. While crunchy peanut butter would be restricted, smooth peanut butter is typically allowed as it does not require significant mastication.

C. Offering ginger ale to a client who is a member of the Mormon faith: Ginger ale is nonalcoholic and caffeine-free options are usually available. Serving ginger ale is generally consistent with Mormon dietary restrictions, which prohibit alcohol and caffeinated beverages, so this does not require intervention.

D. Serving ice cream to a client who prescribed a full-liquid diet: Ice cream is considered a full-liquid food and is consistent with this diet order. It does not violate dietary guidelines, so no intervention is required.

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Correct Answer is C

Explanation

A. "I can have mustard on my sandwiches.": Mustard is high in sodium and can contribute significantly to daily sodium intake, which is contraindicated for clients with cardiomyopathy who need to limit sodium to reduce fluid retention and cardiac workload.

B. "I can season foods with celery salt.": Celery salt contains sodium and is not an appropriate seasoning for clients on a low-sodium diet. Using it can exacerbate fluid retention, hypertension, and worsening heart failure symptoms.

C. "I can eat frozen juice bar for dessert.": Many frozen juice bars are low in sodium and suitable for a heart-healthy, low-sodium diet. Choosing these types of snacks helps the client manage fluid balance and cardiac workload effectively.

D. "I can drink vegetable juice with my meals.": Most commercial vegetable juices are very high in sodium, making them inappropriate for clients who need to restrict sodium intake. Consuming these can lead to fluid retention and increased cardiac strain.

A. The formula infusion rate of the feeding was too slow. B. The formula was given immediately following removal from the refrigerator. C. The feeding tube was partially obstructed during the infusion. D. The client is experiencing delayed gastric emptying.

Correct Answer is B

Explanation

A. The formula infusion rate of the feeding was too slow: A slow infusion rate generally decreases the risk of diarrhea because the gastrointestinal tract has more time to absorb nutrients. Rapid administration is more commonly associated with osmotic diarrhea due to overwhelming intestinal absorption capacity, so a slow rate is an unlikely cause.

B. The formula was given immediately following removal from the refrigerator: Cold formula can irritate the gastrointestinal mucosa and disrupt normal digestive enzyme activity, leading to increased motility and diarrhea. Allowing the formula to reach room or body temperature before administration helps reduce gastric upset and osmotic diarrhea.

C. The feeding tube was partially obstructed during the infusion: Partial obstruction typically slows or interrupts the flow of formula, which may cause bloating or nausea but does not usually result in diarrhea. The decreased delivery rate reduces intestinal osmotic load rather than triggering loose stools.

D. The client is experiencing delayed gastric emptying: Delayed gastric emptying slows the passage of formula into the small intestine, which can cause nausea, vomiting, or reflux, but it does not commonly cause diarrhea. Diarrhea is more associated with rapid gastric emptying or malabsorption rather than delayed emptying.

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A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following actions by the AP requires intervention?

Nursing Test Bank

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