After reviewing a client's intake and output record for the last eight hours, the nurse calculates the client's current fluid balance as how many mL? (Enter numeric value only).

0730-8 oz of orange juice, hard-boiled egg, and toast

0830-voided 200 mL

0900-a cup of water

1200-1 cup of soup, tuna sandwich, and 6 ounces of apple juice

1300 vomitus of 100 mL

1400-voided 250 ml

1430-12 ounce can have carbonated beverage.

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which finding(s) should alert the nurse that further assessment is needed? (Select all that apply.)

Generalized nonpitting edema.

Hypoactive bowel sounds in all 4 quadrants.

Redness at intravenous site.

Urinary output greater than 30 ml per hour.

Frequent productive cough.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A

Generalized nonpitting edema is correct. Nonpitting edema could indicate fluid retention, and it's important to assess for signs of fluid overload, electrolyte imbalances, or underlying cardiac issues.

Choice B

Hypoactive bowel sounds in all 4 quadrants is correct. Hypoactive bowel sounds could suggest gastrointestinal motility issues, which could be a sign of gastrointestinal complications related to TPN.

Choice C

Redness at intravenous site is correct. Redness at the intravenous site could be indicative of infection, infiltration, or irritation. It's important to assess for signs of infection and ensure proper IV site care.

Choice D

Urinary output greater than 30 ml per hour is incorrect. While increased urinary output could indicate adequate hydration, it's not typically a concerning finding unless there are other signs of fluid imbalance. Top of Form

Choice E

Frequent productive cough is correct. A frequent productive cough could indicate respiratory issues, including aspiration pneumonia, which can be a complication of TPN.

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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.

A. High protein. B. High roughage. C. Low cholesterol. D. Low salt.

Correct Answer is A

Explanation

Choice A

High protein should be encouraged. The small reddened area on the coccyx is concerning for a potential pressure ulcer (also known as a pressure sore or bed sore). Pressure ulcers can occur when there is prolonged pressure on a specific area of the skin, often in individuals who are bedridden or have limited mobility. Adequate nutrition, including a high protein diet, is essential for preventing and promoting the healing of pressure ulcers. Protein is crucial for tissue repair and wound healing. A diet high in protein can aid in the recovery of damaged skin and promote the healing process. It helps to maintain and rebuild skin tissue, which is particularly important when dealing with potential pressure ulcers.

Choice B

High roughage should not be encouraged. While dietary fibre (roughage) is important for overall bowel health and regularity, it may not have a direct impact on wound healing in this context.

Choice C

Low cholesterol should not be encouraged. A low cholesterol diet is typically recommended to manage cardiovascular health and reduce the risk of heart disease. While overall health is important, cholesterol levels may not have a direct impact on wound healing in this case.

Choice D

Low salt should not be encouraged. A low salt diet is often recommended for individuals with certain medical conditions, such as hypertension or heart failure. While maintaining a balanced diet is important, salt intake may not be the primary concern when addressing wound healing.

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Naxlex Comprehensive Predictor Exams

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

The nurse is conducting diet teaching for the family of an older client who has a small reddened area on the coccyx. Based on this finding, which diet should the nurse encourage for this client?

Correct Answer is A

Explanation

The nurse is admitting an older client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

When conducting diet teaching for a client who was diagnosed with hypocalcaemia, which foods should the nurse encourage the client to eat? (Select all that apply.)

A client expresses an interest in reducing intake of saturated fats and plans to stop eating hamburgers at lunch. Which menu item should the nurse suggest as an alternative source of protein?

The nurse is caring for an older adult who needs to limit sodium intake. Which food should the nurse encourage the client to avoid?

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only to 0 decimal places)

The nurse is providing dietary education to a client newly diagnosed with Type 2 diabetes mellitus. Which information should the nurse provide?

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon returning home. Which dietary teaching should the nurse include in the discharge instructions?