The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

A salad with three kinds of lettuce and fruit.

Vegetable soup, crackers, and milk.

A peanut butter sandwich with soda and cookies.

A tuna fish sandwich with chips and ice cream.

Answer and Explanation

The Correct Answer is D

A)   Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B)   Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C)   Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.

D)   Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.

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Correct Answer is A

Explanation

The client's history of lung cancer, persistent hoarseness, chronic cough, and labored respirations when speaking indicate potential respiratory complications. Coarse breath sounds may suggest the presence of airway obstruction or fluid accumulation in the lungs, which can be indicative of a worsening condition.

The nurse should intervene promptly by assessing the client's respiratory status further, providing appropriate respiratory support, and notifying the healthcare provider for further evaluation and intervention.

A. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. B. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care. C. Instruct the DAP that a standard face mask is sufficient to be able to provide care for the assigned client. D. Before changing assignments, determine which staff members have fitted particulate filter masks.

Correct Answer is C

Explanation

A) This option is unnecessary because droplet precautions do not require a particulate filter mask. Particulate filter masks are needed for airborne precautions. Sending the UAP for fitting delays care without providing additional safety benefits for droplet precautions.

B) While a standard face mask is appropriate for droplet precautions, the part about getting fitted for a filter mask is unnecessary. It implies that a particulate filter mask is needed, which it is not for droplet precautions. This option also incorrectly suggests that vital signs can be obtained with a standard mask, but personal care requires a particulate filter mask, which is not accurate.

C) Droplet precautions require the use of a standard face mask, not a particulate filter mask (such as an N95 respirator). Particulate filter masks are required for airborne precautions, which are necessary for diseases like tuberculosis, measles, or chickenpox. For droplet precautions, a standard surgical mask is adequate to prevent the transmission of infections like influenza. Thus, the UAP can safely provide care to the client with flu-like symptoms by wearing a standard face mask.

D) This option is unnecessary because a particulate filter mask is not required for droplet precautions. Changing assignments based on this criterion is not needed and could disrupt the workflow without enhancing safety. The focus should be on ensuring staff understand and use the appropriate PPE for droplet precautions.

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The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

Correct Answer is A

Explanation

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer is C

Explanation

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