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 A,D,B,C

Explanation

A. Clear liquid. Clear liquids are the first step in advancing the diet after a period of nothing by mouth (NPO). They are easy to digest and help prevent dehydration.
D. Full liquid. Full liquids are the next step after clear liquids and include liquids and foods that are smooth and easily poured or formed into a liquid at room or body temperature. Examples
include milk, yogurt, and cream-based soups.

B. Pureed. Pureed foods are soft and smooth, requiring minimal chewing. They are often recommended for individuals who have difficulty swallowing or have undergone oral or facial surgery.
C. Mechanical soft. Mechanical soft foods are semi-solid and easily mashed or broken down with a fork. They are suitable for individuals with difficulty chewing or swallowing but can tolerate more texture than pureed foods.

A. Follow low carbohydrate diet with low glycemic index foods. B. Eat a high protein diet three times a day. C. Avoid foods high in potassium. D. Restrict sodium rich foods and excessive oral fluids.

Correct Answer is D

Explanation

A. Follow low carbohydrate diet with low glycemic index foods. This recommendation is more appropriate for managing diabetes rather than glomerulonephritis. Carbohydrate and glycemic index considerations are not the primary dietary concerns for glomerulonephritis patients.
B. Eat a high protein diet three times a day. In glomerulonephritis, kidney function is impaired, and a high protein diet can exacerbate the condition by increasing the workload on the kidneys. Protein intake should often be moderated, not increased.
C. Avoid foods high in potassium. While potassium management may be relevant in certain cases of kidney disease, it is not the primary dietary focus for glomerulonephritis unless hyperkalemia is a specific issue.
D. Restrict sodium rich foods and excessive oral fluids. Reducing sodium intake helps prevent fluid retention and hypertension, both of which can be problematic in glomerulonephritis. Controlling fluid intake also helps manage symptoms and prevent complications associated with 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

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.)

Correct Answer is A,D,B,C

Explanation

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon returning home. Which dietary teaching should the nurse include in the discharge instructions?

Correct Answer is D

Explanation

A medication that causes extreme photosensitivity was recently prescribed for a client. In providing discharge instructions, the nurse should teach this client to increase intake of which foods?

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A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. Which assessment should the nurse complete before contacting the healthcare provider?

A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal from the menu. Which food choice should the nurse advise the client to omit?

The parents of a child with prediabetes report to the nurse that the child wants to join a soccer team. Which information is best for the nurse to offer the parents?

A client who has a body mass index (BMI) of 29 kg/m2 expresses a desire to lose weight. Which action should the nurse implement? Reference Range: Body Mass Index (BMI) Overweight [25.0 to 29.9 kg/m2]

A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?