A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Remove the bedpan from the client's sight.

Provide mouth care before feeding.

Assess for pain prior to mealtime.

Administer antiemetics following the meal.

Answer and Explanation

Correct Answer : B,C

A) Remove the bedpan from the client's sight: This action is not directly related to addressing malnutrition. While it may improve the client's comfort and environment, it does not contribute directly to addressing nutritional needs.

B) Provide mouth care before feeding: This action is appropriate. Ensuring good oral hygiene, including mouth care before meals, can stimulate the appetite and enhance the client's ability to taste and enjoy food. It also helps prevent infections and discomfort associated with poor oral hygiene.

C) Assess for pain prior to mealtime: This action is essential. Pain can significantly affect a client's appetite and ability to eat. By assessing for pain before mealtime, the nurse can identify any discomfort that might interfere with the client's ability to consume food and address it promptly.

D) Administer antiemetics following the meal: While antiemetics may be necessary for some clients who experience nausea or vomiting during or after meals, their administration should be based on individual assessment and prescription by a healthcare provider. Routine administration of antiemetics following meals is not standard practice and may not be appropriate for all clients.

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Correct Answer is ["A","C","D"]

Explanation

A) "I'll make sure his diaper is loose in the front":

This statement indicates understanding because ensuring a loose diaper helps prevent irritation and discomfort to the healing circumcision site. Tight diapers can rub against the area and cause irritation or disrupt the healing process.

B) "I'll apply petroleum jelly to his penis with diaper changes":

While applying petroleum jelly to the penis with diaper changes is a common practice for circumcision care, it is not recommended for the Plastibell technique. Using petroleum jelly can interfere with the plastic ring and may prevent it from falling off naturally.

C) "I'll expect the plastic ring to fall off by itself within a week":

This statement indicates understanding because with the Plastibell technique, the plastic ring is left in place until it falls off on its own, typically within a week after the procedure. It is essential for the client to be aware of this expected outcome.

D) "I'll call the doctor if I see any bleeding":

This statement indicates understanding because it shows recognition of the potential complication of bleeding post-circumcision. While some minor bleeding may occur initially, excessive bleeding should be reported to the doctor promptly for further evaluation and management.

E) "I'll wash his penis with warm water and mild soap each day":

While keeping the area clean with warm water and mild soap is generally recommended for circumcision care, with the Plastibell technique, it is typically advised to avoid washing the area directly until the plastic ring falls off. Direct washing may interfere with the healing process or disrupt the plastic ring. Therefore, this statement does not indicate understanding of circumcision care with the Plastibell technique.

A. Use a syringe to give the client fluids. B. Instruct the client to swallow with their head tilted back. C. Elevate the head of the client's bed. D. Instruct the client to chew on the left side of their mouth.

Correct Answer is C

Explanation

A) Using a syringe to give fluids to a client at risk for dysphagia is not recommended. This method can increase the risk of aspiration, especially if the client has difficulty swallowing. It's essential to assess the client's ability to swallow safely and provide appropriate interventions to minimize the risk of aspiration.

B) Instructing the client to swallow with their head tilted back is not appropriate for managing dysphagia. This technique can lead to aspiration because it interferes with the normal swallowing process and may cause fluids or food to enter the airway. The head should be in a neutral position or slightly flexed forward to facilitate safe swallowing.

C) Elevating the head of the client's bed is a crucial intervention for managing dysphagia and reducing the risk of aspiration. Raising the head of the bed to a semi-Fowler's or high-Fowler's position helps prevent regurgitation of food or fluids into the airway during swallowing. This position promotes better clearance of the esophagus and reduces the likelihood of aspiration pneumonia.

D) Instructing the client to chew on the left side of their mouth is not a specific intervention for managing dysphagia. While some techniques, such as altering food consistency or positioning, may be recommended depending on the individual's swallowing difficulties, chewing on a specific side of the mouth does not address the underlying issue of dysphagia and may not be effective in preventing aspiration.

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A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is C

Explanation

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