After reviewing a client's intake and output record for the last eight hours, the nurse calculates the client's current fluid balance as how many mL? (Enter numeric value only).

0730-8 oz of orange juice, hard-boiled egg, and toast

0830-voided 200 mL

0900-a cup of water

1200-1 cup of soup, tuna sandwich, and 6 ounces of apple juice

1300 vomitus of 100 mL

1400-voided 250 ml

1430-12 ounce can have carbonated beverage.

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which finding(s) should alert the nurse that further assessment is needed? (Select all that apply.)

Generalized nonpitting edema.

Hypoactive bowel sounds in all 4 quadrants.

Redness at intravenous site.

Urinary output greater than 30 ml per hour.

Frequent productive cough.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A

Generalized nonpitting edema is correct. Nonpitting edema could indicate fluid retention, and it's important to assess for signs of fluid overload, electrolyte imbalances, or underlying cardiac issues.

Choice B

Hypoactive bowel sounds in all 4 quadrants is correct. Hypoactive bowel sounds could suggest gastrointestinal motility issues, which could be a sign of gastrointestinal complications related to TPN.

Choice C

Redness at intravenous site is correct. Redness at the intravenous site could be indicative of infection, infiltration, or irritation. It's important to assess for signs of infection and ensure proper IV site care.

Choice D

Urinary output greater than 30 ml per hour is incorrect. While increased urinary output could indicate adequate hydration, it's not typically a concerning finding unless there are other signs of fluid imbalance. Top of Form

Choice E

Frequent productive cough is correct. A frequent productive cough could indicate respiratory issues, including aspiration pneumonia, which can be a complication of TPN.

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Correct Answer is B

Explanation

Choice A

24-hour food recall, food preferences, and allergies is incorrect. While these factors are important for understanding the client's dietary habits and possible dietary restrictions, they do not directly provide information about the client's current nutritional status or overall nutritional health.

Choice B

Body mass index (BMI) and serum albumin level is correct. Body mass index (BMI) and serum albumin level are commonly used parameters to assess a client's nutritional status. These measures provide valuable information about the client's weight, muscle mass, and protein status. Let's break down the options:

Choice C

Triceps skin fold and mid-arm circumference is incorrect. These measurements can provide information about the client's body composition and muscle mass. However, they are not as commonly used as BMI and serum albumin level for assessing nutritional status.

Choice D

Weight loss history and body surface area (BSA) is incorrect. Weight loss history is relevant for understanding changes in the client's weight over time, which can indicate potential malnutrition. However, it's not as comprehensive as BMI, which considers both weight and height. Body surface area (BSA) is not typically used to assess nutritional status.

A. Soft low-residue diet. B. Pureed diet. C. Mechanical soft diet. D. Full liquid diet.

Correct Answer is C

Explanation

Choice A

Soft low-residue diet should not be recommended. This diet is often used for individuals with gastrointestinal issues and aims to reduce the bulk and frequency of bowel movements. It might not be necessary for this client's dental concerns.

Choice B

Pureed diet should not be recommended. A pureed diet involves blending foods to a smooth consistency, which is often recommended for individuals with severe difficulty swallowing or chewing. Since the client has no teeth but doesn't necessarily have difficulty swallowing, a pureed diet might be overly restrictive.

Choice C

Mechanical soft diet should not be recommended. mechanical soft diet consists of foods that are easy to chew and swallow, making it suitable for individuals with dental issues or difficulty chewing. It includes foods that are softer in texture, often cooked until they are tender and easy to manipulate with a fork or spoon. This type of diet would be beneficial for the client in question, as it accommodates his lack of teeth and ensures that he can consume a variety of foods without the need for extensive chewing.

Choice D

Full liquid diet should be recommended. A full liquid diet includes foods in liquid form, such as soups, milk, and juice. While it's easy to swallow, it might not provide the necessary variety and texture for the client's nutritional needs.

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Naxlex Comprehensive Predictor Exams

The nurse is admitting an older client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

Correct Answer is B

Explanation

During the admission assessment, an older male client who has no teeth tells the nurse that he can not find his dentures at home. His dietary prescription is a regular diet. What diet request should the nurse recommend for this client?

Correct Answer is C

Explanation

Which client is at greatest risk for aspiration?

An adult woman with a body mass index (BMI) of 21 tells the nurse that she wants to lose 10 pounds (4.5 kg). Which intervention is most important for the nurse to implement?

The nurse is providing care for a client with an absolute neutrophil count (ANC) of 400. Which action should the nurse perform prior to delivering the meal tray to the client's room? Reference Range Neutrophils (ANC) [Reference Range: 2500 to 8000 mm3 or 2500 to 8000 cells/uL]

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only to 0 decimal places)

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

While caring for a client receiving total parenteral nutrition (TPN), it is most important for the nurse to monitor which of the client's lab values?

The nurse is caring for an older client with that is exhibiting signs of confusion. Which intervention should the nurse implement?

The nurse is conducting diet teaching for the family of an older client who has a small reddened area on the coccyx. Based on this finding, which diet should the nurse encourage for this client?