A client diagnosed with viral hepatitis is complaining of “no appetite” and “losing my taste for food.” What instruction would the nurse give the client to provide adequate nutrition?

Select foods high in fat.

Increase intake of fluids, including juices.

Eat a good supper, when anorexia is less severe.

Eat less often, preferably only three large meals daily.

Answer and Explanation

The Correct Answer is B

Choice A reason: High-fat foods may worsen nausea in hepatitis, reducing appetite further. Fluids and juices provide nutrition and hydration, making this incorrect, as it’s less suitable than the nurse’s recommendation to ensure adequate nutrition in a client with anorexia.

Choice B reason: Increasing fluid intake, including nutrient-rich juices, provides calories and hydration, combating anorexia in hepatitis. This aligns with nutritional support strategies, making it the correct instruction the nurse would give to ensure adequate nutrition for the client.

Choice C reason: Supper timing doesn’t address overall anorexia; small, frequent meals are better. Juices provide easier nutrition, making this incorrect, as it’s less effective than the nurse’s advice to increase fluids for a hepatitis client with poor appetite.

Choice D reason: Three large meals may overwhelm a client with hepatitis and anorexia, worsening intake. Fluids and juices are easier to tolerate, making this incorrect, as it’s not the nurse’s best instruction for ensuring adequate nutrition in this client.

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Correct Answer is B

Explanation

Choice A reason: Discussing pulse oximetry findings with the client is appropriate and promotes understanding, not requiring intervention. A blood pressure cuff on the same arm affects readings, making this incorrect, as it’s a correct nursing action for the client with Raynaud’s and diabetes.

Choice B reason: A blood pressure cuff on the same arm as the pulse oximeter disrupts blood flow, causing inaccurate readings, especially in Raynaud’s disease. This requires intervention, aligning with monitoring accuracy standards, making it the correct situation for the nurse to address immediately.

Choice C reason: Placing the pulse oximeter on the ring finger is appropriate, avoiding Raynaud’s-affected areas. A cuff on the same arm is problematic, making this incorrect, as it’s a standard placement not requiring intervention in the client’s monitoring setup.

Choice D reason: Instructing assistive personnel to obtain readings is acceptable if within their scope. A cuff on the same arm affects accuracy, making this incorrect, as it’s not an issue compared to the intervention needed for the pulse oximeter placement error.

Choice E reason: An LPN recording the pulse from the oximeter is within their role and not problematic. A cuff on the same arm requires intervention, making this incorrect, as it’s a correct action unlike the inaccurate monitoring setup needing nurse correction.

A. Hyponatremia. B. Hypocalcemia. C. Hyperkalemia. D. Hypokalemia. E. Metabolic acidosis. F. Metabolic alkalosis.

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

Explanation

Choice A reason: Sodium of 130 mEq/L indicates hyponatremia, likely from vomiting-induced sodium loss. This aligns with the child’s electrolyte profile and symptoms, making it a correct imbalance the nurse would identify as most likely based on the lab values and clinical presentation.

Choice B reason: Calcium of 9.5 mg/dL is normal, not indicating hypocalcemia. Hyponatremia and metabolic alkalosis match the labs (sodium 130, HCO3 30), making this incorrect, as it does not reflect the child’s electrolyte imbalances from vomiting and irregular pulse.

Choice C reason: Potassium of 3.3 mEq/L is low, not high, ruling out hyperkalemia. Hyponatremia and metabolic alkalosis fit the labs and vomiting history, making this incorrect, as it contradicts the child’s potassium level in the nurse’s assessment of imbalances.

Choice D reason: Potassium of 3.3 mEq/L suggests mild hypokalemia, but hyponatremia (sodium 130) is more prominent with vomiting. Metabolic alkalosis is also evident, making this partially correct but incorrect as the primary imbalance compared to hyponatremia in the child’s profile.

Choice E reason: HCO3 of 30 mEq/L indicates alkalosis, not acidosis, due to vomiting-induced hydrogen ion loss. Hyponatremia and metabolic alkalosis are correct, making this incorrect, as it contradicts the child’s alkalotic state in the nurse’s evaluation of lab values.

Choice F reason: HCO3 of 30 mEq/L indicates metabolic alkalosis, common with vomiting due to loss of acidic gastric contents. This, with hyponatremia, aligns with the child’s labs and symptoms, making it a correct imbalance the nurse would identify in the assessment.

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A client diagnosed with viral hepatitis is complaining of “no appetite” and “losing my taste for food.” What instruction would the nurse give the client to provide adequate nutrition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for a client diagnosed with Type 1 diabetes and Raynaud’s disease. The orders include continuous pulse oximetry monitoring. Which situation requires an intervention by the nurse?

Correct Answer is B

Explanation

A child has a 2-day history of vomiting, hypoactive bowel sounds, and an irregular pulse. Electrolyte values are sodium, 130 mEq/L; potassium, 3.3 mEq/L; calcium, 9.5 mg/dL; and HCO3, 30 mEq/L. Which of the following imbalances is the child most likely to have? (Select all that apply)

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

Explanation

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