Edited Text
A nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?

Pureed

Soft

Mechanical soft

Answer and Explanation

The Correct Answer is C

Choice A Reason:

A pureed diet consists of foods that are blended to a smooth consistency. This type of diet is typically recommended for clients who have severe swallowing difficulties or are at risk of aspiration. While it can be easier to consume for those with significant dental issues, it may not provide the variety and texture that a mechanical soft diet offers, which can be more satisfying and nutritionally adequate for someone with multiple cavities and missing teeth.

Choice B Reason:

A soft diet includes foods that are easy to chew and swallow but are not necessarily blended or pureed. This diet is often recommended for clients recovering from surgery or those with mild chewing difficulties. However, for a client with multiple cavities, chipped, and missing teeth, a soft diet might still pose challenges in terms of chewing and could lead to discomfort or inadequate nutrition.

Choice C Reason:

A mechanical soft diet is specifically designed for individuals who have difficulty chewing but do not require pureed foods. This diet includes foods that are easy to chew and swallow, such as ground meats, cooked vegetables, and soft fruits. It provides a balance of texture and nutrition, making it the most appropriate choice for a client with multiple cavities, chipped, and missing teeth. This diet helps ensure the client can eat comfortably and maintain adequate nutrition.

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Correct Answer is A

Explanation

Choice A reason: Applying compression stockings is a key prophylactic intervention to prevent complications of immobility, such as deep vein thrombosis (DVT) and venous thromboembolism (VTE). Compression stockings help improve blood circulation in the legs by applying graduated pressure, which reduces the risk of blood clots forming in the deep veins. This is particularly important for immobile patients who are at higher risk of developing DVT due to prolonged periods of inactivity.

Choice B reason: Raising all side rails is primarily a safety measure to prevent falls and does not directly address the complications of immobility. While it is important for patient safety, it does not have a significant impact on preventing issues like DVT, pressure ulcers, or muscle atrophy. Therefore, it is not considered a prophylactic intervention for immobility-related complications.

Choice C reason: Inserting a urinary catheter is not a prophylactic intervention for preventing complications of immobility. Catheters are used to manage urinary retention or incontinence but can increase the risk of urinary tract infections (UTIs) if not managed properly. They do not address the primary complications associated with immobility, such as DVT or pressure ulcers.

Choice D reason: Using friction-reducing devices is important for preventing pressure ulcers and skin injuries in immobile patients. These devices help minimize friction and shear forces on the skin, which can lead to pressure ulcers. While this is a valuable intervention, it is not as comprehensive as compression stockings in preventing a range of immobility-related complications.

A. Encourage coughing and deep breathing. B. Elevate the client to a high Fowler’s position. C. Administer prescribed analgesic medication. D. Administer oxygen at 2 L/min.

Correct Answer is D

Explanation

Choice A reason: Encouraging coughing and deep breathing is important for postoperative care to prevent complications such as atelectasis and pneumonia. However, with an oxygen saturation of 85%, the immediate priority is to address the client’s hypoxemia. Once oxygen levels are stabilized, coughing and deep breathing exercises can be encouraged.

Choice B reason: Elevating the client to a high Fowler’s position can help improve lung expansion and ease breathing. While this is a beneficial intervention, it is not the first priority when the client’s oxygen saturation is critically low. Administering oxygen should be the initial step to quickly improve oxygenation.

Choice C reason: Administering prescribed analgesic medication is essential for managing the client’s pain, which can also help improve breathing patterns. However, pain management should follow the immediate correction of hypoxemia. Ensuring adequate oxygenation takes precedence over pain relief in this scenario.

Choice D reason: Administering oxygen at 2 L/min is the first action the nurse should take. With an oxygen saturation of 85%, the client is experiencing significant hypoxemia, which needs to be corrected promptly to prevent further complications. Oxygen therapy will help increase the oxygen levels in the blood and improve the client’s overall condition.

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Edited TextA nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

Correct Answer is A

Explanation

A nurse is caring for a client who has returned to the unit following a surgical procedure of the abdomen. The client is complaining of pain 6/10. On assessment, the client’s oxygen saturation is 85%. Which action should the nurse take first?

Correct Answer is D

Explanation

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Edited Text
A nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?