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 C
Explanation
Choice A rationale
Listening for bowel sounds for only 1 minute in one area is insufficient to determine their presence or absence accurately. Bowel motility and thus bowel sounds can be intermittent, and listening for a brief period might miss infrequent sounds. A more extended auscultation is necessary to assess bowel activity adequately.
Choice B rationale
Listening for 2 minutes in each quadrant totals 8 minutes of auscultation, which is more comprehensive than 1 minute. However, bowel sounds can still be sporadic. A longer duration of listening in at least one quadrant where sounds might be present is needed before concluding they are absent.
Choice C rationale
Auscultating for bowel sounds for a total of 5 minutes (not necessarily 5 minutes in each quadrant, but listening attentively in different areas for a cumulative of 5 minutes) is the generally accepted minimum duration to confidently declare bowel sounds absent, termed "silent bowel sounds.”. This extended listening time increases the likelihood of detecting any intermittent bowel activity.
Choice D rationale
Listening for 10 minutes is even more thorough, but if no bowel sounds are heard after a continuous and attentive 5-minute auscultation, it is generally considered clinically significant for absent bowel sounds. Prolonged auscultation beyond 5 minutes is usually not necessary unless there are specific clinical indications.
Correct Answer is ["200"]
Explanation
Step 1 is: The total volume to be infused is 50 mL.
Step 2 is: The infusion time is 15 minutes.
Step 3 is: To find the milliliters per hour, first convert minutes to hours: 15 minutes ÷ 60 minutes/hour = 0.25 hours.
Step 4 is: Calculate the infusion rate in mL/hour: 50 mL ÷ 0.25 hours = 200 mL/hour. The nurse will infuse the drug at 200 mL per hour.
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