What meal option should a nurse choose for a client with fluid volume excess who has been placed on a low-sodium diet?
Baked chicken, canned peas & carrots, macaroni & cheese, and hot tea
Pepperoni pizza, salad, and a diet soda
Baked turkey breast, corn on the cob, dinner roll, and skim milk
Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers, and iced tea
The Correct Answer is C
A. Baked chicken, canned peas & carrots, macaroni & cheese, and hot tea: This meal option contains canned vegetables, which are likely to be high in sodium due to added salt for preservation. Additionally, macaroni and cheese are typically high in sodium, and hot tea may contain added sodium if processed or prepared with salt. Therefore, this option is not suitable for a client on a low-sodium diet.
B. Pepperoni pizza, salad, and a diet soda: Pepperoni pizza is a high-sodium food due to the processed meats and cheese. Salad can be a healthy option, but it depends on the dressing and toppings; if these are high in sodium, it may not be appropriate. Diet soda typically does not contain sodium, but it is not an ideal beverage choice for a client with fluid volume excess. Overall, this option is not suitable for a low-sodium diet.
C. Baked turkey breast, corn on the cob, dinner roll, and skim milk: This is the correct answer. Baked turkey breast is a lean protein source that is naturally low in sodium. Corn on the cob and skim milk are also low in sodium. A dinner roll may contain some sodium, but if chosen wisely, it can be a suitable option for a low-sodium diet. Overall, this meal option provides a balanced and low-sodium meal for a client with fluid volume excess.
D. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers, and iced tea: Bologna, potato chips, and iced tea are all high-sodium food items and not suitable for a client on a low-sodium diet. While sliced cucumbers are low in sodium, they alone cannot offset the high sodium content of the other items in this meal option.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.
B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.
C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.
D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.
Correct Answer is A
Explanation
A. Ask about medications the client currently takes: The first nursing action should be to gather information about potential causes of the pink coloration of the urine. Certain medications, foods, and medical conditions can cause urine discoloration. Asking about the medications the client currently takes can help identify if the pink coloration is due to a medication side effect, such as certain antibiotics, laxatives, or antipsychotics, which can cause urine to appear pink or reddish.
B. Check the client's vital signs: While assessing the client's vital signs is important for obtaining baseline data and assessing the client's overall health status, it may not provide immediate insights into the cause of the pink urine. Vital signs are unlikely to reveal the underlying cause of urine discoloration.
C. Notify the healthcare provider about the bleeding: Notifying the healthcare provider about the presence of pink urine is important, but it should not be the first action taken without gathering more information. Before contacting the healthcare provider, the nurse should assess the client's medications, recent dietary intake, and medical history to identify potential causes of the urine discoloration.
D. Send the urine to the lab for culture and sensitivity: Sending the urine to the lab for culture and sensitivity is not the first action indicated in this scenario. While urine analysis may be warranted to further evaluate the pink urine, it should be done after assessing the client's medications and obtaining additional information to determine the likely cause of the urine discoloration.
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