A nurse is caring for a client with diarrhea.
Which intervention can help prevent further complications in a client with diarrhea?
Tell the client to avoid bananas and apples.
Encourage a clear liquid diet.
Offer solid foods such as vegetables and beans.
Help the client lie flat in a supine position.
The Correct Answer is B
Choice A rationale
Recommending the avoidance of bananas and apples is counterproductive for a client suffering from diarrhea. These specific fruits are actually part of the BRAT diet, which stands for bananas, rice, applesauce, and toast. These foods are low in fiber and help bind the stool, making them beneficial during recovery. Restricting them removes a potential source of potassium and pectin, which help stabilize the gut. Fiber management is essential for maintaining normal electrolyte and fluid balance.
Choice B rationale
Encouraging a clear liquid diet is the primary intervention to prevent dehydration, which is the most severe complication of diarrhea. Clear liquids such as broth, gelatin, and electrolyte replacement drinks provide essential hydration without overtaxing the gastrointestinal tract. This approach allows the bowel to rest while ensuring the client receives necessary fluids. Maintaining hydration is critical because excessive water loss leads to hypotension and electrolyte imbalances, where normal sodium levels are 135 to 145 mEq/L.
Choice C rationale
Offering solid foods like vegetables and beans is inappropriate during an acute episode of diarrhea. These foods are typically high in insoluble fiber and complex carbohydrates, which can increase gas production and stimulate further peristalsis. This mechanical stimulation can worsen the frequency of stools and increase abdominal cramping. The gut requires a period of rest and easily digestible nutrients rather than bulky roughage. Reintroducing these foods should only happen once the stool consistency begins to normalize.
Choice D rationale
Helping the client lie flat in a supine position does not directly treat or prevent complications related to diarrhea. In fact, if the client is experiencing nausea or vomiting alongside diarrhea, lying flat could increase the risk of aspiration. While rest is important, position changes do not address the physiological need for fluid replacement or bowel rest. Nursing care should focus on metabolic stability and skin integrity rather than a specific supine position, which provides no therapeutic benefit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The cecum is the proximal, pouch-like portion of the large intestine that marks the transition from the small intestine via the ileocecal valve. It serves as a reservoir for chyme received from the ileum, allowing for the initial absorption of water and salts. Anatomically, it is located in the right iliac fossa and provides the base of attachment for the vermiform appendix. This structure is essential for beginning the dehydration of fecal matter.
Choice B rationale
The ascending colon is the second segment of the large intestine, following the cecum in the gastrointestinal sequence. It travels superiorly along the right side of the posterior abdominal wall until it reaches the inferior surface of the liver at the hepatic flexure. While it is a major site for water reabsorption, it is not the first part of the large intestine. Its primary role involves transporting waste upward toward the transverse segment for further processing.
Choice C rationale
The appendix is a narrow, finger-like vestigial tube attached to the posteromedial surface of the cecum, roughly 2 cm below the ileocecal junction. Although it contains lymphoid tissue and may play a role in the immune system or gut flora maintenance, it is an appendage rather than a primary segment of the large intestine. It does not function as the initial entry point for digestive waste entering the colonic system from the small intestine.
Choice D rationale
The transverse colon is the longest and most mobile part of the large intestine, extending across the abdomen from the right hepatic flexure to the left splenic flexure. It follows the ascending colon in the digestive pathway. Its physiological role involves the continued extraction of water and electrolytes from liquid stool as it moves toward the descending colon. Because it is the third major segment, it cannot be considered the first part of the large intestine.
Correct Answer is B
Explanation
Choice A rationale
Inspecting the mouth is an important aspect of overall hygiene and monitoring for oral candidiasis or dryness related to oxygen therapy, but it does not address the most immediate physical risk of the nasal cannula apparatus itself. While the mouth should be assessed regularly, every 24 hours is a generic interval that might miss early signs of mucosal irritation or other complications in a client with chronic obstructive respiratory disease.
Choice B rationale
Nasal cannulas exert constant pressure and friction on the sensitive skin of the nares and behind the ears. For clients with chronic respiratory issues, skin integrity is a priority because breakdown can lead to infection and discomfort, potentially decreasing compliance with oxygen therapy. Assessing the nares every 8 hours allows for early detection of redness or pressure ulcers, which is standard nursing practice for maintaining skin integrity in patients using external medical devices.
Choice C rationale
Checking oxygen flow and pulse oximetry every 48 hours is dangerously infrequent for a client with a chronic obstructive respiratory disease. These clients require frequent monitoring to ensure they are maintaining adequate saturation, typically between 88.
Choice D rationale
Checking the patency of the cannula only once every 24 hours is insufficient for ensuring continuous and effective oxygen delivery. Cannulas can easily become dislodged, kinked, or clogged with nasal secretions, leading to a sudden drop in the fraction of inspired oxygen. Frequent checks of the equipment are necessary to ensure the client receives the prescribed flow rate, especially since these clients rely on supplemental oxygen to maintain baseline metabolic functions and prevent exacerbations.
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