When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

The urine meter attached to the urinary drainage bag is completely full.

A feeding is infusing at 40 mL/hour through an enteral feeding tube.

There is a large dependent loop in the client's urinary drainage tubing.

Purulent drainage is present around the insertion site of the feeding tube.

Answer and Explanation

The Correct Answer is C

A. The urine meter attached to the urinary drainage bag is completely full. While this observation requires attention, it does not pose an immediate risk to the client's safety. The nurse should
empty the urine meter promptly to prevent overflow.

B.   A feeding is infusing at 40 mL/hour through an enteral feeding tube. This rate of infusion is within the typical range for enteral feedings and does not indicate an immediate safety concern. However, the nurse should assess the client's tolerance to the feeding.
C.   There is a large dependent loop in the client's urinary drainage tubing. A large dependent loop in the urinary drainage tubing can lead to urinary stasis and increase the risk of urinary tract
infections or catheter-associated complications. It requires immediate intervention to prevent complications.
D.   Purulent drainage is present around the insertion site of the feeding tube. While purulent drainage indicates a potential infection at the insertion site, it may not require immediate
intervention unless the client exhibits signs of systemic infection such as fever or increased white blood cell count.

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Correct Answer is C

Explanation

A. Oatmeal with honey, applesauce, and pear nectar. While oatmeal may be suitable for some

individuals with dysphagia, adding honey and pear nectar increases the risk of aspiration due to their liquid consistency. Applesauce may also pose a risk depending on the client's swallowing ability.
B. Pancakes with syrup, link sausage, and orange juice. This meal contains several items that may be difficult for someone with dysphagia to swallow safely, including pancakes with syrup and link sausage. Orange juice may also pose a risk of aspiration.
C. An oral nutritional supplement. Oral nutritional supplements are designed for individuals with dysphagia who have difficulty swallowing solid foods. They provide essential nutrients in a
liquid form that is easier to swallow and can help maintain adequate nutrition in clients with dysphagia.
D. Scrambled eggs, bacon, toast, milk, and coffee. This meal contains several items that may be difficult for someone with dysphagia to swallow safely, including scrambled eggs and toast. Milk and coffee may also pose a risk of aspiration.

A. Cherries and cranberries. B. Apples and blueberries. C. Carrots and green beans. D. Avocados and bananas.

Correct Answer is D

Explanation

A. Cherries and cranberries. These fruits are generally low in potassium and are safe for people with chronic kidney disease (CKD).
B. Apples and blueberries. These fruits are also low in potassium and safe for CKD patients.

C. Carrots and green beans. These vegetables are low in potassium and safe for CKD patients.

D. Avocados and bananas. Both avocados and bananas are high in potassium. Clients with stage 4 CKD need to limit their intake of high-potassium foods to prevent hyperkalemia, which can be dangerous given their impaired kidney function.

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When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has dysphagia as the result of a stroke. Which breakfast should the nurse provide this client?

Correct Answer is C

Explanation

The nurse is caring for a client admitted with chronic kidney disease advancing to stage 4. The nurse should instruct the client to limit the ingestion of which type of foods?

Correct Answer is D

Explanation

A client who has been NPO has a new prescription to progress the diet as tolerated. In which sequence should the nurse progress the client's diet? (Arrange from first action on top to last on the bottom.)

The nurse is planning a nutrition class for vegans. Which food should the nurse encourage to be combined with other foods to enhance the nutritional intake in the vegan diet?

A client with diabetes mellitus tells the nurse of using cranberry juice to help prevent urinary tract infections. Which instruction should the nurse provide?

When conducting diet teaching for a client who was diagnosed with iron-deficiency anemia, which food(s) should the nurse encourage the client to eat? Select all that apply.

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In reviewing the dietary teaching for a young adult client with hyperthyroidism, the nurse learns that the client has increased the intake of protein and calories. Which action should the nurse take?

The nurse is administering a client's medications through a feeding tube. One of the medications is an enteric-coated tablet. Which action would be best for the nurse to take?