A nurse is updating a plan of care for a client who has a new prescription for a calorie count. Which of the following interventions should the nurse Include?

Record between-meal snacks on the calorie count form.

Begin the calorie count with the client's next evening meal.

Exclude liquids in the total calorie count.

Complete the calorie count for a 5-day period.

Answer and Explanation

The Correct Answer is A

A. Record between-meal snacks on the calorie count form: Between-meal snacks contribute significantly to a client's total daily caloric intake and must be included to obtain an accurate calorie count. Omitting these snacks can result in an incomplete dietary assessment, potentially leading to inaccurate evaluations of the client's nutritional status.
B. Begin the calorie count with the client's next evening meal: Calorie counts should begin as soon as the prescription is initiated, not delayed until a specific mealtime. Waiting to begin with the evening meal may result in missed intake data and reduce the accuracy of the assessment. Timely initiation ensures the healthcare team captures a complete and accurate picture of the client’s intake patterns.
C. Exclude liquids in the total calorie count: Liquids, especially those containing calories such as juice, milk, nutritional supplements, or sweetened beverages, must be included in a calorie count. Excluding these items can underestimate the client’s actual caloric intake and interfere with proper evaluation and planning of their nutritional needs.
D. Complete the calorie count for a 5-day period: A standard calorie count is typically conducted over a 72-hour (3-day) period, which is sufficient to identify trends and provide nutritional insights. Extending the count unnecessarily to 5 days may not yield additional useful data and can burden both clients and staff. The focus should be on consistency and completeness within the accepted timeframe.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Has occasional incontinence. Incontinence increases moisture exposure and contributes to skin breakdown risk, but "occasional" incontinence presents a moderate rather than the highest level of risk. Consistent exposure would be more concerning.
B. Eats one serving of protein per day. Inadequate protein intake significantly impairs tissue repair and skin integrity, placing the client at the highest risk for pressure injuries. Protein is essential for maintaining skin health and supporting the healing process.
C. Responds to verbal commands. This indicates that the client is alert and cognitively intact, allowing for active participation in repositioning and care, which lowers the risk for skin breakdown.
D. Is able to walk short distances. Some level of mobility helps relieve pressure and promotes circulation, both of which reduce the likelihood of pressure injury development. Limited mobility presents less risk than poor nutritional intake.

A. Clear-colored urine B. Decreased urine specific gravity C. Increased hematocrit D. Hypertension

Correct Answer is C

Explanation

A. Clear-colored urine: Clear-colored urine typically indicates adequate hydration or even overhydration. In Clostridium difficile, where the client may be experiencing profuse diarrhea, clear urine would not align with fluid volume deficit. This finding suggests the kidneys are excreting diluted urine, which is not consistent with dehydration.
B. Decreased urine specific gravity: A decreased urine specific gravity reflects dilute urine and usually points to overhydration or an inability to concentrate urine. In a client with C. difficile and likely diarrhea-related fluid loss, the expected finding would be a concentrated urine with increased specific gravity, not decreased.
C. Increased hematocrit: An increased hematocrit indicates hemoconcentration, which occurs when plasma volume is reduced due to fluid loss. In the setting of Clostridium difficile infection, where fluid is lost rapidly through diarrhea, this rise in hematocrit is a classic marker of fluid volume deficit. It reflects the relative increase in red blood cells due to a lower plasma volume.
D. Hypertension: Hypertension is more commonly associated with fluid volume excess or other cardiovascular conditions. In cases of fluid volume deficit, hypotension or orthostatic hypotension is more expected due to decreased circulating blood volume. Therefore, high blood pressure would not support the diagnosis of dehydration in this context.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is updating a plan of care for a client who has a new prescription for a calorie count. Which of the following interventions should the nurse Include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a pressure injury risk assessment on a client. Which of the following findings places the client at the highest risk for skin breakdown?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory findings of a client who has Clostridium difficile. Which of the following findings should indicate to the nurse that the client is experiencing a fluid volume deficit?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results of a client who is taking warfarin and notes a decrease in the INR. The nurse should ask the client if they have recently increased their intake of which of the following foods?

A nurse is providing postpartum education about newborn feedings to a client who has recently given birth. Which of the following information should the nurse include about bottle feeding?

A nurse is planning eating strategies with a client who has nausea from equilibrium imbalance. Which of the following strategies should the nurse recommend?

A nurse is assessing a client who has received treatment for hypocalcemia. Which of the following findings indicates the treatment has been effective?

A nurse is evaluating the use of a nipple shield by a client who is breastfeeding. Which of the following actions by the client demonstrates correct use of the nipple shield?

A nurse is initiating an intermittent enteral feeding for a client who has a new gastrostomy tube. Which of the following actions should the nurse take first?

A nurse is caring for a client who follows a vegan diet. The nurse should identify that the client is at risk for which of the following deficiencies?