Saunders Nutrition, Elimination

The nurse is providing dietary instructions to a client with a diagnosis of ulcerative colitis. The client is prescribed to follow a low residue diet during episodes of diarrhea. Which food should the nurse instruct the client to avoid?

Fresh corn on the cob

A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action?

Notify the registered nurse of the findings.

The nurse employed in a well-baby clinic is reinforcing nutrition instructions to the mother of a 1-month-old infant. Which instruction should the nurse provide the mother?

Offer breast milk or formula as the main food.

A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?

TPN contains concentrated carbohydrates and raises blood glucose.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates and is unable to obtain any residual tube feeding. Which action should the nurse take next?

Turn the client to the side and attempt to aspirate again.

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral?

Vitamin B12

The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply.

-Yogurt -Cottage cheese

An abdominal postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. The nurse collects data regarding which important item before advancing the diet to solids?

Dentition and ability to chew

The nurse is reinforcing diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

"Canned foods are inexpensive and are good to use on a low-sodium diet."

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

"Fresh foods such as fruits and vegetables are high in sodium."

The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response?

"I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme."

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

"I need to decrease fiber in my diet."

The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply.

-Tofu -Broccoli -Sardines -Mustard greens

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home with family caregivers. Which nursing response would be appropriate at this time?

"Tell me more about your concerns with your feedings after going home."

A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse?

"That is because the empty stomach sends signals to the brain to stimulate hunger."

A caregiver states that the client eats only about 25% of the food that is offered and is losing weight. The caregiver asks the nurse about feeding the client by a tube into the stomach. Which initial response by the nurse would be appropriate?

"Tube feedings can provide adequate amounts of required nutrients."

The nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. The client has had a swallowing study done that shows the client is at risk for aspiration and is able to feed self. The nurse should review which interventions with the unlicensed assistive personnel (UAP)? Select all that apply.

-Add the prescribed thickener to liquids. -Observe client for episodes of coughing or choking.

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply.

-Apples -White bread -Egg whites

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse should tell the client that which foods are best to include in the diet for this disorder? Select all that apply

-Apples -Whole-grain bread

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.

-Apply disposable gloves. -Lubricate the enema tube and insert it approximately 4 inches. -Clamp the tubing if the client expresses discomfort during the procedure. -Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items should the nurse instruct the client to avoid? Select all that apply.

-Bacon -Salami -Processed oat cereals

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply.

-Bread and butter -Carrots and peas -Peppers and onions

A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.

-Broth -Coffee -Gelatin

A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods should the client avoid? Select all that apply.

-Cabbage -Mushrooms -Strawberries

The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply.

-Central line dressing changes per protocol -Blood glucose monitoring around the clock -Using an electronic infusion pump with the infusion -Reviewing prescribed blood laboratory values including electrolytes

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? Select all that apply.

-Character of drainage -Presence of blood clots -Amount of drainage emptied -Client complaint of pain/spasms -Type and amount of irrigation fluid used

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. Select all that apply.

-Check the bladder for distention. -Review intake and output record. -Check to ensure drainage tubing is not kinked. -Ask the client about bladder spasms and discomfort.

The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply.

-Clams and mussels -Lean beef and chicken liver

A client who has calcium phosphate kidney stones tells the nurse, "Tell me what I can do, so that I never have this pain again." Which instructions should the nurse plan to include in the reinforcement of dietary instructions? Select all that apply.

-Decrease sodium intake. -Limit the intake of whole grains. -Limit protein to 5 to 7 servings per week.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply.

-Document the amount of residual. -Reinstill the residual and administer the feeding.

The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply.

-Eggs -Chicken

The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply.

-Eggs -White bread with butter

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

-Empty pouch when ⅓ to ½ full. -The stoma should be moist and pink to red. -The skin barrier should be within 1⁄16 to ⅛ inch of the stoma. -Change the appliance about every 3 days, or sooner, if it is leaking effluent.

A client has a diagnosis of hyperphosphatemia. The nurse reinforces instructions by telling the client to eliminate which items from the diet? Select all that apply.

-Fish -Chicken

A client with hypertension has been prescribed a low-sodium diet. The nurse reinforcing instructions about foods that are allowed should include which foods in a list provided to the client? Select all that apply.

-Fresh tomato -Summer squash

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply.

-Have the client void and then perform the bladder scan. -If residual urine is less than 100 mL, continue to monitor.

An older client complains of chronic constipation. Which instructions should the nurse reinforce with the client? Select all that apply.

-Increase fluids to at least eight glasses a day. -Respond in a timely manner to the urge to defecate.

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? Select all that apply.

-Increase your fluid intake. -Include more fiber in your diet. -Ferrous sulfate changes the color of stool to black. -Iron slows colonic acid and often leads to constipation.

The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy? Select all that apply.

-Kiwi -Bananas -Avocados

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

-Lightly scrub the stoma with soap and water. -Cut the opening on the appliance ½ inch larger than stoma.

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply.

-Maintain adequate fluid intake of 2 quarts. -Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. -Take all discharge medication as prescribed including antibiotics, and notify your primary health care provider if symptoms or signs of a UTI reappear. -Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating.

The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items should be included in the client's diet? Select all that apply.

-Milk -Wild caught salmon

Which factors contribute to the problem of stress incontinence? Select all that apply.

-Obesity -Sneezing

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.

-Oranges -Broccoli -Grapefruit

The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods? Select all that apply.

-Oysters -Spinach -Kidney beans

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? Select all that apply.

-Placing the scan head on the symphysis pubis and aiming toward the bladder -Applying a generous amount of transmission/conductivity gel across the client's abdomen

The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply.

-Potatoes -Avocados -Salt substitute

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat foods from which nutrient categories to promote wound healing? Select all that apply.

-Protein -Vitamin C

The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply.

-Raisins -Kiwifruit -Bananas

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse reinforces dietary teaching about the types of foods to avoid. The nurse determines that there is a need for further teaching if the client states that which food choices are good? Select all that apply.

-Sauerkraut -American cheese

A client has been diagnosed with functional incontinence. Which interventions are most appropriate to care for this type of incontinence? Select all that apply.

-Schedule toileting every 2 hours. -Modify clothing for easy removal -Assess environment for obstacles. -Set up schedule of cues such as mealtimes, awakening, and bedtime.

The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?

1000 calories

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.

250

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? Refer to chart.

3 Long-term Silicon Size 16 Fr 5 mL balloon with sterile water

A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. What is the maximal amount of calories the client should receive in an 8-hour period if the tube feeding is not interrupted? Fill in the blank.

360

The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula should the nurse plan to add to fill the feeding bag?

400 mL of formula

The client is to receive a soapsuds enema. Which is the best position for administering an enema? Refer to figure.

A (stomach down)

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Advance the catheter to the bifurcation and inflate the balloon.

A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which sign?

Air embolism

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?

Baked turkey

A client states that he has removed all dairy foods from his diet because he is lactose intolerant. The nurse plans care for the client knowing which information?

Calcium and protein are valuable nutrients and need to be supplemented in some form.

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?

Cheese

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?

Chicken breast, broccoli, strawberries, and milk

A primary health care provider prescribes a parenteral nutrition solution to start at 50 mL/hr by infusion pump via an established subclavian central line. After 2 hours of initiating the parenteral nutrition infusion, the client suddenly complains of difficulty in breathing and chest pain. Which action would the nurse prepare to do first?

Clamp the parenteral nutrition infusion.

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which items during an episode of nausea?

Cool, clear liquids

Which ostomy location would most likely need to be irrigated? Refer to figure.

D

A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray?

Eggs

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?

Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.

A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?

Fluid overload

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?

Fat-free beef broth

The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?

Fever and pruritic urticaria

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat

Green, leafy vegetables

The nurse is reinforcing dietary instructions to a client with tuberculosis who has lost weight. The nurse reinforces instructions for the client to increase intake of protein and vitamin C. The nurse determines that teaching has been effective when the client selects which food items in the daily diet?

Hamburger and oranges

A 17-year-old pregnant client is being seen at the obstetric clinic. The nurse is reviewing the following laboratory results, which were obtained 2 hours after breakfast: hemoglobin 10 g/dL (100 mmol/L), sodium 140 mEq (140 mmol/L), glucose 110 mg/dL (6 mmol/L), potassium 4.1 mEq (4.1 mmol/L). Which dietary instruction should the nurse reinforce for this client?

Increase the amount of red meats.

A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. The nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can to see if it contains which ingredient?

Lactose

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?

Milk

The nurse is assigned to care for a client receiving total parenteral nutrition via the subclavian vein. The nurse should identify which intervention in the plan of care for the client as the priority?

Monitoring the insertion site for signs of infection

A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?

Notify the primary health care provider (PHCP) of the client's signs and symptoms.

A client has been on total parenteral nutrition for 8 weeks. The primary health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response should be to explain that the primary health care provider is concerned about which phenomenon?

Rebound hypoglycemia

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?

Scallops

The nurse should recognize that which type of enema has the highest risk of water intoxication?

Tap water

The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan?

The presence of food allergies

A client is receiving total parenteral nutrition and has been NPO. The primary health care provider (PHCP) prescribed small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth?

The presence of the swallow reflex

The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate which potential complication?

There may be an infection at the central catheter site, which can lead to septicemia.

A primary health care provider prescribes an intravenous fat emulsion solution for a client who will be receiving parenteral nutrition (PN). The nurse should explain to the client the administration of the fat emulsion solution is for which reason?

To provide essential fatty acids and additional calories