When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

The urine meter attached to the urinary drainage bag is completely full.

A feeding is infusing at 40 mL/hour through an enteral feeding tube.

There is a large dependent loop in the client's urinary drainage tubing.

Purulent drainage is present around the insertion site of the feeding tube.

Answer and Explanation

The Correct Answer is C

A. The urine meter attached to the urinary drainage bag is completely full. While this observation requires attention, it does not pose an immediate risk to the client's safety. The nurse should
empty the urine meter promptly to prevent overflow.

B.   A feeding is infusing at 40 mL/hour through an enteral feeding tube. This rate of infusion is within the typical range for enteral feedings and does not indicate an immediate safety concern. However, the nurse should assess the client's tolerance to the feeding.
C.   There is a large dependent loop in the client's urinary drainage tubing. A large dependent loop in the urinary drainage tubing can lead to urinary stasis and increase the risk of urinary tract
infections or catheter-associated complications. It requires immediate intervention to prevent complications.
D.   Purulent drainage is present around the insertion site of the feeding tube. While purulent drainage indicates a potential infection at the insertion site, it may not require immediate
intervention unless the client exhibits signs of systemic infection such as fever or increased white blood cell count.

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Correct Answer is A

Explanation

A. "Be sure to drink sugar-free cranberry juice." This is important advice for a client with diabetes because regular cranberry juice often contains high levels of added sugars, which can cause blood sugar levels to spike. Choosing sugar-free options helps manage blood glucose
levels more effectively.

B. "Excess cranberry juice can be constipating." Cranberry juice is not typically associated with causing constipation. This statement is less relevant to the client's concern about preventing urinary tract infections.
C. "Drinking cranberry juice does not prevent infection." While cranberry juice is not a guaranteed method to prevent UTIs, it is believed to help reduce the risk of infections by preventing bacteria from adhering to the urinary tract. Thus, this statement is partially incorrect.
D. "Cranberries may increase the effect of insulin." There is no substantial evidence to suggest that cranberries significantly alter the effect of insulin. This statement is not a typical concern associated with cranberry juice consumption.

A. Whole wheat cereal with milk, bacon, and coffee. B. Pancakes, bacon, fruit, and milk. C. Scrambled eggs, sausage, toast, and orange juice. D. Bowl of hot oatmeal with milk, fruit, and lemon tea.

Correct Answer is C

Explanation

A. Whole wheat cereal with milk, bacon, and coffee is incorrect. While it contains some protein (milk and bacon), it lacks adequate protein and calorie density needed for burn healing.
B. Pancakes, bacon, fruit, and milk is incorrect. While this meal provides carbohydrates and some protein, it does not offer enough protein for optimal wound healing.
C. Scrambled eggs, sausage, toast, and orange juice is correct. Burn patients require high-protein and high-calorie meals to support tissue repair and metabolic demands. Eggs and sausage provide high-quality protein, while toast and juice add necessary carbohydrates for energy.
D. A bowl of hot oatmeal with milk, fruit, and lemon tea is incorrect. Although this meal has carbohydrates and some protein, it is not protein-dense enough for burn recovery.

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When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diabetes mellitus tells the nurse of using cranberry juice to help prevent urinary tract infections. Which instruction should the nurse provide?

Correct Answer is A

Explanation

Which breakfast selection should the nurse encourage a client to eat who is hospitalized with partial-thickness and full-thickness burns to both legs?

Correct Answer is C

Explanation

The nurse is performing a nutritional assessment on a client who is a professional dancer. Which issue reported by the client should alert the nurse to perform further assessment?

When conducting diet teaching for a client who was diagnosed with iron-deficiency anemia, which food(s) should the nurse encourage the client to eat? Select all that apply.

The nurse is helping develop a meal plan based on nutritional guidelines for an older adult client being discharged to home with the client's spouse. Which statement by the client and spouse best indicates an understanding of the nutritional guidelines when planning meals?

The nurse is planning food selections with a client who has moderate hyponatremia. Which food choice should the nurse recommend to this client?

A medication that causes extreme photosensitivity was recently prescribed for a client. In providing discharge instructions, the nurse should teach this client to increase intake of which foods?

The nurse instructs a client with type 2 diabetes mellitus (DM) to avoid refined sugar and carbohydrates. Choosing which food indicates that the client understands the diet teaching?