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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Poor time management: This option is the correct answer. Poor time management occurs when a nurse fails to allocate sufficient time to complete essential nursing tasks, such as assessments and medication administration, due to excessive focus on non-priority activities, such as providing emotional and spiritual support. In this scenario, Nurse Z's inability to plan and allocate adequate time for essential nursing duties indicates poor time management skills.

B. Neglect: Neglect involves the failure to provide necessary care or attention to a client's needs, resulting in harm or potential harm. While Nurse Z's excessive focus on emotional and spiritual support may lead to neglect of other essential nursing responsibilities, the primary issue in this scenario is poor time management rather than deliberate neglect.

C. Fraud: Fraud involves intentional deception or misrepresentation for personal gain. There is no indication in the scenario that Nurse Z's actions involve deceit or manipulation for personal benefit, so fraud is not applicable in this context.

D. Intentional tort: Intentional torts involve deliberate actions that result in harm to another person. Nurse Z's failure to plan enough time for assessments and medication administration appears to stem from poor time management rather than intentional harm, so an intentional tort is not applicable in this scenario.

A. 4 in. (10.2 cm) B. 5 in (12.7 cm) C. 6 in. (15.25 cm) D. 2 in. (5.1 cm) E. 3 in. (7.6 cm)

Correct Answer is ["A","E"]

Explanation

When administering an enema to an adult patient with constipation, the nurse must insert the tubing into the patient's rectum to deliver the enema solution effectively. However, it's crucial to avoid inserting the tubing too far to prevent injury or discomfort to the patient. The recommended insertion distance varies depending on the individual patient's anatomy and the type of enema being administered.

A. 4 in. (10.2 cm):

Inserting the enema tubing approximately 4 inches (10.2 cm) into the patient's rectum is considered a safe and effective distance for most adult patients. This depth allows the enema solution to reach the sigmoid colon, facilitating the evacuation of stool and relieving constipation without risking insertion too deeply into the rectum.

B. 5 in (12.7 cm): Inserting the tubing 5 inches into the rectum is generally deeper than necessary and may increase the risk of injury or discomfort. This distance is not typically recommended for safe and effective administration of an enema.

C. 6 in. (15.25 cm): Inserting the tubing 6 inches into the rectum is deeper than necessary and may increase the risk of injury or discomfort. This distance is generally not recommended for safe and effective administration of an enema.

D. 2 in. (5.1 cm): Inserting the tubing 2 inches into the rectum is not considered a safe and effective distance for many adult patients. This distance does not allow for the effective delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

E. 3 in. (7.6 cm): Inserting the tubing 3 inches into the rectum is also considered a safe and effective distance for many adult patients. This distance allows for the delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

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What meal option should a nurse choose for a client with fluid volume excess who has been placed on a low-sodium diet?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Nurse Z is extremely attentive to their client's emotional & spiritual needs. The nurse spends up to 45 minutes each day providing the psychosocial support. As a result, the nurse does not plan enough time to perform assessments or give medications on time. This nurse is liable for:

Correct Answer is A

Explanation

The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

Correct Answer is ["A","E"]

Explanation

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