A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?
Suggest fresh fruits and vegetables
Offer small, frequent meals:
Provide a diet of pureed foods
Encourage fluids with meals
None
None
The Correct Answer is B
A. Suggest fresh fruits and vegetables: This is incorrect because clients with HIV, especially those with immunosuppression, might be at increased risk for foodborne illnesses from fresh produce. Proper food handling and possibly cooked vegetables might be recommended instead.
B. Offer small, frequent meals: This is correct because small, frequent meals can help manage symptoms like nausea or loss of appetite, which are common in clients with HIV.
C. Provide a diet of pureed foods: This is unnecessary unless the client has specific swallowing difficulties. Generally, pureed foods are not required unless indicated by the client's condition.
D. Encourage fluids with meals: This is incorrect as consuming large amounts of fluids with meals may lead to early satiety, which is not ideal for clients needing to maintain or gain weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply a heat pack to the client's lower abdomen: This is incorrect as applying heat can worsen inflammation and increase the risk of rupture; ice packs are generally used instead.
B. Place the client in semi-Fowler's position: This is correct as the semi-Fowler's position helps reduce pain and pressure on the abdomen and can improve comfort before surgery.
C. Give the client a clear liquid diet: This is incorrect as a clear liquid diet is not appropriate for a client with acute appendicitis who may require NPO (nothing by mouth) status prior to surgery.
D. Administer an enema to the client: This is incorrect as enemas are contraindicated in acute appendicitis due to the risk of perforation and worsening of the condition.
Correct Answer is ["A","E","F"]
Explanation
A. Obtain vital signs every 5 min.
Rationale: The client's vital signs indicate hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). Frequent monitoring of vital signs is essential to assess changes in the client's condition and guide further interventions.
E. Initiate a second peripheral IV.
Rationale: Given the client's low urine output (110 mL over 6 hours) and signs of possible hypovolemia or fluid imbalance, establishing an additional IV line can facilitate the administration of fluids and medications more effectively.
F. Apply oxygen.
Rationale: The client's oxygen saturation is slightly decreased at 96% on room air. Applying supplemental oxygen can help improve oxygenation and alleviate symptoms related to decreased oxygen levels.
Not Recommended Actions:
B. Place the client in high-Fowler's position: This position might not be appropriate for a client with chest pain and potential hypovolemia, as it could exacerbate hypotension.
C. Perform gastric lavage: The output from the nasogastric tube (800 mL sanguineous) does not indicate a need for gastric lavage unless there is a specific reason to suspect gastrointestinal bleeding that requires immediate intervention.
D. Prepare to administer anticoagulants: There is no indication of thromboembolism or need for anticoagulants based on the provided information. The focus should be on addressing hypotension and fluid imbalance.
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