A client with severe malnutrition is admitted to the hospital.
Which intervention should the nurse implement first?

Insert nasogastric tube and begin enteral feeding.

Teach the patient to increase protein intake and to eat five to seven times a day.

Implement strict NPO status and initiate total parenteral nutrition (TPN).

Teach the patient to rinse their mouth with alcohol-based mouthwash prior to meals.

Answer and Explanation

The Correct Answer is A

Choice A rationale

For a client with severe malnutrition, immediate intervention is necessary to address nutritional deficiencies. Inserting a nasogastric tube and beginning enteral feeding is the first step to provide essential nutrients, stabilize the patient's condition, and prevent further complications from malnutrition.

Choice B rationale

Teaching the patient to increase protein intake and to eat more frequently is important but not the immediate priority in a case of severe malnutrition. This can be addressed after initial stabilization and nutritional support.

Choice C rationale

Total parenteral nutrition (TPN) is an option for patients who cannot tolerate enteral feeding, but initiating strict NPO status without first attempting enteral feeding is not the best initial approach. Enteral feeding is generally preferred if the gastrointestinal tract is functional.

Choice D rationale

Rinsing the mouth with alcohol-based mouthwash before meals is not a priority in managing severe malnutrition. It does not address the immediate need for nutritional support and could be harmful if ingested.

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Correct Answer is C

Explanation

Choice A rationale

Dosimeter badges are used for monitoring radiation exposure, not for handling chemotherapy. They are worn by healthcare workers working in areas with ionizing radiation to track their cumulative exposure and ensure it stays within safe limits.

Choice B rationale

Lead aprons are also used to protect against radiation exposure, not chemotherapy. They shield the body from ionizing radiation but do not provide protection from the cytotoxic effects of chemotherapy agents.

Choice C rationale

Personal protective equipment (PPE), including gloves and gowns, is essential for safely handling chemotherapy drugs to prevent skin contact and inhalation of hazardous chemicals. This reduces the risk of exposure to these toxic agents, protecting both the nurse and the patient.

Choice D rationale

Chemotherapy waste should be disposed of in designated chemotherapy waste containers, not in standard sharps containers. These specialized containers ensure that hazardous waste is handled according to safety regulations, reducing the risk of environmental contamination and exposure.

A. Facial swelling and jugular vein distension (JVD). B. Muscle weakness, confusion, polyuria, and polydipsia. C. Flank pain, elevated uric acid, and cardiac monitor reveals an abnormal rhythm. D. Elevated liver function tests, jaundice, and blistering skin rash.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale

Facial swelling and jugular vein distension (JVD) are indicative of superior vena cava syndrome (SVCS), not tumor lysis syndrome (TLS). SVCS occurs when the superior vena cava, which carries blood from the head, neck, upper chest, and arms to the heart, is obstructed. This can lead to facial swelling, cyanosis, and distended neck veins due to increased venous pressure.

Choice B rationale

Muscle weakness, confusion, polyuria, and polydipsia are symptoms of hypercalcemia. Hypercalcemia is characterized by elevated levels of calcium in the blood, which can cause neuromuscular and cognitive symptoms, excessive urination, and increased thirst.

Choice C rationale

Tumor lysis syndrome (TLS) is characterized by rapid destruction of tumor cells, leading to elevated levels of uric acid, potassium, and phosphate. Symptoms include flank pain due to uric acid crystallization in the kidneys, and abnormal heart rhythms due to hyperkalemia.

Choice D rationale

Elevated liver function tests, jaundice, and blistering skin rash are symptoms of liver toxicity or hepatic dysfunction, possibly due to drug-induced liver injury. These symptoms are not related to tumor lysis syndrome (TLS).

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A client with severe malnutrition is admitted to the hospital.Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A client with severe malnutrition is admitted to the hospital.
Which intervention should the nurse implement first?