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

Advising the client that too much fruit can irritate the colon is not the right choice. While it's true that excessive consumption of certain fruits can cause gastrointestinal discomfort, this information is not directly related to celiac disease or the selected meal.

Choice B

Informing the client that oatmeal contains gluten is the right choice. Celiac disease is an autoimmune disorder in which consuming gluten, a protein found in wheat, rye, and barley, triggers an immune response that damages the small intestine. Oatmeal itself is naturally gluten-free, but it is often processed in facilities that also process gluten-containing grains, which can lead to cross-contamination. Therefore, it's important for individuals with celiac disease to choose certified gluten-free oats to avoid adverse reactions.

Choice C

Commending the client for selecting fat-free milk is not the best choice. While choosing a healthier milk option is beneficial for overall health, it is not the most important action in this situation, considering the client's celiac disease.

Choice D reason;

Encouraging the client to choose decaffeinated coffee is not the right choice. The choice of caffeinated or decaffeinated coffee is a matter of preference and is not directly related to celiac disease or the potential for gluten exposure from the oatmeal.

A. Body mass index (BMI) of 17. B. Decrease in the appetite. C. Dry mucosal membranes. D. Weight of 227 pounds (103 kg).

Correct Answer is A

Explanation

Choice A

Body mass index (BMI) of 17 is the correct finding. A low Body Mass Index (BMI) is a common indicator of malnutrition. BMI is a measurement that considers a person's weight in relation to their height. A BMI of 17 suggests that the person is underweight, which can be indicative of malnutrition. Malnutrition is characterized by inadequate intake of calories, protein, vitamins, and minerals that are essential for maintaining health and well-being.

Choice B

Decrease in appetite is not correct finding. While a decrease in appetite might contribute to malnutrition, it's a symptom rather than a definitive indicator.

Choice C

Dry mucosal membranes are not the correct finding. Dry mucosal membranes can be related to dehydration or other conditions, but they are not specific enough to confirm malnutrition on their own.

Choice D

Weight of 227 pounds (103 kg) is not the correct finding. This weight is not necessarily indicative of malnutrition on its own. It's important to consider the individual's height, BMI, and other factors when assessing malnutrition.

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Naxlex Comprehensive Predictor Exams

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

Correct Answer is A

Explanation

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

While caring for a client receiving total parenteral nutrition (TPN), it is most important for the nurse to monitor which of the client's lab values?

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

A female client with haemorrhoids tells the nurse that she understands the need to avoid eating nuts and seeds to prevent inflammation. How should the nurse respond?

In conducting community health teaching, the nurse plans to describe foods that will help prevent rickets. What food product should the nurse recommend as the best dietary source for preventing rickets?

During the admission assessment, an older male client who has no teeth tells the nurse that he can not find his dentures at home. His dietary prescription is a regular diet. What diet request should the nurse recommend for this client?

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