Nurses' Notes

A 28-year-old female who has started weightlifting. g nutritional counselling due to unwanted weight loss. 8, and she is hoping to build muscle mass and see weight gain. The client denies drinking, smoking, or drug es an oral contraceptive and uses melatonin for sleep.

Review H and P and nurse's notes.

Click to highlight the foods that are both nutrient and energy dense. 24-hour diet history:

0630

1 whole-wheat tortilla, 4 oz chicken breast, 4 of an avocados, 1/4 cup of salsa

1030

1 cup coffee, 2 tbsp half and half, 1 small apple, 1 tbsp almond butter

1200

1 cup spinach, 4 oz ground turkey with taco seasoning. 1/4 cup cheddar cheese, 2 bananas

1500

6 cashews

1900

1 cup regular soda, 6 oz white fish, 1/2 white potato, 2 tbsp butter, 1⁄2 cup green beans

2200

Choice A

Demonstrating correct measurement of the tube insertion length is the first priority. Inserting a nasogastric tube to the appropriate length is crucial for ensuring that the tube reaches the stomach and is not inserted too far. Incorrect insertion length can lead to complications, discomfort, or potential harm to the patient. Therefore, demonstrating and ensuring the correct measurement of the tube insertion length takes priority.:

Choice B

Reminding the nurse to apply lubricant to the tube before insertion is not first priority. Applying lubricant helps ease the insertion process, but it is not the most critical step to prioritize initially.

Choice C

Confirming that the nurse has auscultated the client's bowel sounds is not the first priority. Bowel sounds assessment is important to ensure proper placement, but this step can be done after ensuring the correct measurement of the insertion length.

Choice D

Elevating the head of the bed before the nurse inserts the tube is not the first priority: Elevating the head of the bed helps facilitate the passage of the tube into the stomach, but it is not the first priority in this context.

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.