A nurse is calculating a client's fluid intake over the past 8 hours.

The client had one 8-ounce cup of coffee, 3 ounces of juice, and 12 ounces of soda.

The client's water pitcher had 800 mL and 200 mL remaining.

The client also had IV fluids infusing at 40 mL per hour via an IV pump.

How many mL should the nurse document as the client's total intake for the shift?

Choice A rationale

While saturated fats are part of the body's metabolic processes, their primary negative impact at elevated levels isn't directly interfering with the overall metabolic pathways in a disruptive manner. The issue lies more specifically with their influence on lipid profiles rather than a broad metabolic dysfunction.

Choice B rationale

Saturated fats, primarily found in animal products, have been shown to increase low-density lipoprotein (LDL) cholesterol levels in the blood. Elevated LDL cholesterol is a major risk factor for atherosclerosis, a condition where plaque builds up in the arteries, narrowing them and increasing the risk of heart disease and stroke.

Choice C rationale

Hydrogenation is a process used to solidify unsaturated fats, creating trans fats, which are even more detrimental to cholesterol levels than saturated fats. Saturated fats themselves are naturally solid at room temperature and do not inherently need to be hydrogenated to achieve this state.

Choice D rationale

Saturated fats do not typically block the absorption of essential nutrients. The digestive system is designed to absorb a variety of fats, including saturated fats, along with other nutrients. The primary concern with high intake of saturated fats is their negative impact on blood lipid levels.

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.