RN Nutrition Online Practice 2023 A

A nurse is caring for a client on a medical-surgical unit. Exhibit 1: Nurses' Notes 0700: Client presents to the emergency department with reports of severe abdominal pain, inability to eat, and peripheral edema. Client rates pain as 10 on a scale of 0 to 10. Pancreatic enzymes obtained and client sent for abdominal ultrasound. Ketorolac IV administered for pain and temperature. 0900:Client admitted to medical surgical unit for treatment of acute pancreatitis. Exhibit 2: Vital Signs 0700:Temperature 38.7° C (101.7° F)Heart rate 98/min Respiratory rate 18/minBlood pressure 136/89 mm HgSpO2 98% on room air Which of the following nursing interventions are the priority in the client's care? (Select All That Apply) - Monitor pancreatic enzyme levels. - Administer antibiotics. - Measure intake and output. - Administer pain medication PRN. - Obtain daily weights.

- Monitor pancreatic enzyme levels. - Administer antibiotics. - Administer pain medication PRN. When prioritizing hypothesis, and using the urgent versus non-urgent priority framework, the nurse should recognize that administering pain medications as needed, monitoring pancreatic enzyme levels, and administering antibiotics are the priority interventions in the client's plan of care. Controlling a client's pain is a priority intervention to promote client comfort. Monitoring pancreatic enzyme levels determines the effectiveness of treatment and can indicate a worsening of a client's condition. Antibiotic therapy is instituted to reduce infection. Pancreatitis causes inflammation that can injure intestinal mucosa, allowing the normal flora in the gut to multiply, and producing opportunistic infection. While measuring intake and output and obtaining daily weights would be included in the client's plan of care, these are not priority interventions.

A nurse is caring for a client. Exhibit 1: Nurses' Notes When prioritizing hypothesis, and using the urgent versus non-urgent priority framework, the nurse should recognize that administering pain medications as needed, monitoring pancreatic enzyme levels, and administering antibiotics are the priority interventions in the client's plan of care... Click to highlight the findings that indicate an improvement in the client's condition. To deselect a finding, click on the finding again.

-Client is alert and oriented to person, place, time, and situation -Denies dizziness upon standing -Abdomen soft and rounded with normoactive bowel sounds active in all 4 quadrants -Urine output of 300 mL in past 8 hr -Skin warm, dry, and intact -Capillary refill 2 seconds These are expected findings for a client who has received IV fluids to treat a fluid volume deficit.

A nurse is providing dietary instructions for a client who has a prescription for warfarin. Which of the following foods should the nurse recommend the client eat in moderation while taking this medication?

Correct Answer: Leafy green vegetables The nurse should recommend the client eat in moderation and maintain consistent intake of leafy green vegetables, which contain a natural form of vitamin K that can negate the anticoagulation effects of warfarin. Incorrect: Whole grains Whole grains do not affect the action of warfarin. Fruits with skin Fruits with skin do not affect the action of warfarin. Nuts and seeds Nuts and seeds do not affect the action of warfarin.

A nurse is assessing a client's risk for pressure injuries using a skin risk assessment tool. The client eats more than half of most meals but occasionally refuses a meal. Which of the following information should the nurse document on the nutrition category of the skin risk assessment tool?

Correct Answer: 3 (Adequate) A client who eats more than half of most meals, occasionally refuses a meal, and has four servings of protein each day scores a 3 (Adequate) in the nutrition category of the skin risk assessment tool. Incorrect: 1 (Very Poor) A client who scores a 1 (Very Poor) in the nutrition category of the skin risk assessment tool never finishes a complete meal, drinks little fluid, and does not drink any dietary supplements. 2 (Probably Inadequate)A client who scores a 2 (Probably Inadequate) in the nutrition category of the skin risk assessment tool only eats about half of meals or snacks and only occasionally takes dietary supplements. 4 (Excellent) A client who scores a 4 (Excellent) in the nutrition category of the skin risk assessment tool eats most of every meal, eats plenty of protein, and occasionally eats between meals.

A nurse is caring for a client who expresses a desire to lose weight. Which of the following actions should the nurse take first?

Obtain a 24-hr dietary recall. The first action the nurse should take using the nursing process is to obtain a diet history, such as a 24-hr dietary recall. Having the client write down everything consumed over a 24-hr period is a crucial component of the assessment process to identify eating behaviors and, therefore, be able to recommend dietary modifications based on the data received.