A client has just completed eating her noon meal.
Which nutritional documentation is the most informative?
Patient drank most of her liquids without difficulty.
Patient ate all her lunch.
Patient ate 50% of a heart-healthy diet without difficulty, and drank 360 mL of liquids.
Assisted patient with feeding a liquid diet, chokes frequently.
The Correct Answer is C
Choice A rationale
Stating that the patient drank most liquids without difficulty is a general observation but lacks specific details about the quantity consumed and the type of diet. It provides limited nutritional information.
Choice B rationale
Saying the patient ate all her lunch is brief but doesn't specify the type or amount of food consumed. "Lunch" can vary greatly in nutritional content, making this documentation less informative.
Choice C rationale
This documentation provides specific details about the patient's intake, including the percentage of the heart-healthy diet consumed (50%), indicating the amount of solid food, and the exact volume of liquids ingested (360 mL). It also notes the absence of difficulty, offering a more comprehensive nutritional picture.
Choice D rationale
Documenting assistance with feeding a liquid diet and frequent choking is important for safety but doesn't quantify the amount of liquid consumed or the patient's overall nutritional intake from the meal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Sterile water is not the preferred solution for routine irrigation of a gastrostomy tube. Typically, tap water is recommended for irrigation in most home and long-term care settings for established PEG tubes, as it is cost-effective and generally safe. Sterile water is usually reserved for initial post-operative irrigation or in immunocompromised patients as per specific physician orders.
Choice B rationale
Keeping the head of the bed elevated at least 30 degrees is crucial for a client with a gastrostomy tube, especially one who has dysphagia and is at high risk for aspiration. Elevating the head of the bed helps to prevent reflux of stomach contents into the esophagus and subsequent aspiration into the lungs, reducing the risk of aspiration pneumonia. This position should be maintained during and after feedings and medication administration.
Choice C rationale
While maintaining oral hygiene is important for all patients, including those with gastrostomy tubes, moistening the client's lips with lemon glycerin swabs is generally discouraged. Lemon glycerin swabs can dry out the mucous membranes of the mouth and may not provide adequate hydration. Plain water or a moisturizing oral swab is a better choice for maintaining oral comfort.
Choice D rationale
Measuring the client's abdominal girth can be a useful assessment for detecting abdominal distension, which might indicate feeding intolerance or other complications related to the gastrostomy tube. However, it is not a primary intervention immediately following PEG tube placement. Ensuring proper positioning to prevent aspiration is a more critical initial intervention for a client with dysphagia.
Correct Answer is C
Explanation
Choice A rationale
While it is important to inform the physician about the delay in the TPN solution, the immediate priority is to maintain the patency of the central venous catheter and prevent hypoglycemia. Calling the MD should occur after taking steps to address the immediate risk.
Choice B rationale
Giving the patient a high-protein snack will not address the immediate issue of the TPN running out and the risk of hypoglycemia associated with the abrupt cessation of a high-glucose solution. TPN provides a significant amount of glucose, and suddenly stopping it can lead to a drop in blood sugar.
Choice C rationale
Hanging a bag of 10% dextrose solution (D10W) is the most appropriate immediate action. This will provide a continuous source of glucose to prevent hypoglycemia while waiting for the new TPN bag from the pharmacy. D10W is often used as a bridge solution in this situation. Normal blood glucose levels are typically 70-110 mg/dL.
Choice D rationale
Flushing the line and waiting for the pharmacy to supply the next bag without infusing any solution puts the patient at significant risk for hypoglycemia and can also lead to catheter occlusion. Maintaining a continuous infusion, even of D10W, is crucial. .
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