Which of the following items on the tray should the nurse remove?

Vanilla pudding.

Cranberry juice.

Beef broth.

Orange gelatin.

Answer and Explanation

Correct Answer : A,D

Choice A rationale

Vanilla pudding is often restricted in dysphagia diets due to its smooth, slippery texture, which can be difficult to control in the oral cavity and increases the risk of aspiration into the airway. Individuals with dysphagia may have impaired swallowing mechanisms, making thin, liquid-like consistencies particularly hazardous.

Choice B rationale

Cranberry juice is a thin liquid and poses a significant aspiration risk for a patient with dysphagia. Thin liquids are difficult to manage in the mouth and throat, increasing the likelihood of the liquid entering the trachea instead of the esophagus. Patients with swallowing difficulties often require thickened liquids to improve bolus control.

Choice C rationale

Beef broth is a clear liquid and, similar to cranberry juice, presents a high risk of aspiration for a patient with dysphagia. Its thin consistency makes it challenging for individuals with impaired swallowing to control its movement, potentially leading to it entering the airway and causing respiratory complications.

Choice D rationale

Orange gelatin, while seemingly semi-solid, often melts into a thin liquid in the mouth due to body temperature. This change in consistency makes it difficult to control and increases the risk of aspiration in patients with dysphagia. Gelatin's slippery texture further compounds this risk.

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Correct Answer is A

Explanation

Choice A rationale

Auscultation of the abdomen for bowel sounds should be performed prior to any manipulation such as inspection, palpation, or percussion. Palpation and percussion can stimulate or inhibit bowel motility, potentially altering the sounds heard and leading to an inaccurate assessment of baseline bowel activity.

Choice B rationale

Palpating the abdomen involves applying pressure, which can stimulate bowel motility and increase bowel sounds. Auscultating after palpation might not reflect the client's true baseline bowel sounds.

Choice C rationale

Checking for kidney tenderness involves percussing the costovertebral angle, which is located on the back and does not directly impact bowel sounds. However, it is still a form of manipulation that should ideally occur after auscultation of the abdomen to avoid any potential influence on bowel sounds.

Choice D rationale

Percussion of the abdomen involves tapping the abdominal surface to assess underlying structures. This manipulation can also alter bowel motility and the characteristics of bowel sounds. Therefore, auscultation should precede percussion for an accurate assessment.

A. Energy. B. Electrolytes. C. Minerals. D. Vitamins.

Correct Answer is A

Explanation

Choice A rationale

Carbohydrates are the body's primary source of energy. They are broken down into glucose, which cells use for fuel to perform various functions, including muscle contraction, nerve impulse transmission, and maintaining body temperature.

Choice B rationale

Electrolytes, such as sodium, potassium, and chloride, are minerals that carry an electrical charge and are crucial for fluid balance, nerve function, and muscle contraction. While some foods containing carbohydrates may also contain electrolytes, providing energy is not their primary function. Normal ranges for serum sodium are 135-145 mEq/L, potassium is 3.5-5.0 mEq/L, and chloride is 95-105 mEq/L.

Choice C rationale

Minerals are inorganic substances that the body needs for various functions, including building strong bones, transmitting nerve impulses, and maintaining fluid balance. Examples include calcium, iron, and zinc. While essential, they are not primarily known for providing direct energy. Normal ranges for serum calcium are 8.5-10.5 mg/dL, iron varies by gender (males: 65-175 mcg/dL, females: 50-170 mcg/dL), and zinc is 70-120 mcg/dL.

Choice D rationale

Vitamins are organic compounds that the body needs in small amounts for various metabolic processes. They do not directly provide energy but help the body utilize energy from carbohydrates, fats, and proteins. Examples include vitamin C, vitamin D, and B vitamins. Normal ranges vary widely depending on the specific vitamin.

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Which of the following items on the tray should the nurse remove?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking a client's bowel sounds.At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is A

Explanation

A nurse is teaching a patient about the importance of balancing proteins, carbohydrates, and fats in the diet.The nurse identifies that the teaching about carbohydrates is understood when the patient states that carbohydrates are known for providing which of the following?

Correct Answer is A

Explanation

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