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 C

Explanation

A) Less than 2.5 cm of rubra lochia on perineal pad:

The amount of lochia on the perineal pad is an indicator of postpartum bleeding and uterine involution but does not specifically indicate bladder distention.

B) Client report of increased thirst:

Increased thirst may indicate dehydration, which can occur postpartum, but it is not a specific sign of bladder distention.

C) Fundus palpable to right of midline:

This finding suggests bladder distention. A full bladder can displace the uterus to the right side of the midline. Bladder distention can hinder uterine contractions and increase the risk of postpartum hemorrhage. Emptying the bladder can help the uterus contract effectively and prevent complications.

D) Client report of frequent uterine contractions:

Frequent uterine contractions are expected in the immediate postpartum period as the uterus undergoes involution. However, this finding does not specifically indicate bladder distention.

A. Wipe dentures before storing them in a dry container at night. B. Floss dentures as part of daily cleaning. C. Use a washcloth to clean the denture surfaces. D. Wrap gloved fingers with gauze to remove dentures.

Correct Answer is D

Explanation

A) Wipe dentures before storing them in a dry container at night: This instruction is correct. Dentures should be cleaned before storage to remove any debris or food particles. Storing dentures in a dry container overnight helps prevent bacterial growth and maintains their shape.

B) Floss dentures as part of daily cleaning: Flossing dentures is not typically necessary, as they are not natural teeth with interdental spaces. Instead, dentures should be cleaned using a denture brush or soft-bristled toothbrush to remove plaque and debris.

C) Use a washcloth to clean the denture surfaces: While a washcloth can be used to clean the denture surfaces, it may not be as effective as using a denture brush or soft-bristled toothbrush specifically designed for cleaning dentures. These tools are better at removing plaque and debris without damaging the denture material.

D) Wrap gloved fingers with gauze to remove dentures: This instruction is incorrect. When removing dentures, it's essential to use both hands to grasp them firmly and gently rock them back and forth to release the seal. Using gloved fingers wrapped with gauze may not provide enough grip and could potentially damage the dentures or injure the gums.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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