Unit 3- NCLEX- Therapeutic Diets/Nutrition/Elimination

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 would the nurse inflate the balloon? Immediately inflate the balloon Insert the catheter 2.5cm to 5cm and inflate the balloon Advance the catheter to the bifurcation and inflate the balloon Insert the catheter until resistance is met and inflate the balloon

Advance the catheter to the bifurcation and inflate the balloon Rationale: Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine, continues to advance the catheter to the point of bifurcation, and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The balloon should not be inflated when urine is first observed, after advancing several more centimeters, or when resistance is felt.

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse would tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply. Fish Apples Almonds White bread Egg whites Whole-grain pasta

Apples White bread Egg whites Rationale: Phosphorus is in many foods, especially meats, dairy, and whole grains. Foods low in phosphorus include apples, white bread, and egg whites. Fish, almonds, and whole-grain pasta have significant amounts of phosphorus.

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 would the nurse instruct the client to avoid? Select all that apply. Bacon Salami Tomatoes Summer Squash Processed oat cereals

Bacon Salami Processed oat cereals Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) is indicative of hypernatremia. Based on this finding, the nurse should instruct the client to avoid foods high in sodium, such as processed foods including cereals and meats (bacon and salami). Summer squash and tomatoes are low in sodium.

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 Beef and potato salad Avocados and mushrooms

Bread and butter Carrots and peas Peppers and onions Rationale: Clients taking thiazide or loop diuretics need to have adequate potassium intake and benefit from dietary teaching about the potassium values of foods. Bread and butter, carrots and peas, and peppers and onions are relatively low sources of potassium. Meats and certain fruits and vegetables are high in potassium and include beef and potato salad and avocados and mushrooms.

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 Pudding Ice cream Vegetable juice

Broth Coffee Gelatin Rationale: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include water, bouillon, clear broth, carbonated beverages, gelatin, lemonade, Popsicles, and regular or decaffeinated coffee or tea. Pudding, ice cream, and vegetable juices are allowed on a full liquid diet.

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? Leafy green vegetables will provide all of the necessary calcium Calcium supplements only will be needed to supplement for dairy products Lactose enzymes must be taken to eliminate the effects of lactose intolerance Calcium and protein are valuable nutrients and need to be supplemented in some form

Calcium and protein are valuable nutrients and need to be supplemented in some form Rationale: Clients who are lactose intolerant experience symptoms of bloating, cramping, and diarrhea. Calcium and protein need to be supplemented in some form in the diet of the client with lactose intolerance. Lactose enzymes may help clients with lactose intolerance, but they may not eliminate the client's problems. An individual generally does not consume enough leafy green vegetables daily to obtain sufficient calcium.

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? Auscultate the client's lung sounds Clamp the parenteral nutrition infusion Obtain the client's blood glucose level Perform an electrocardiogram (ECG)

Clamp the parenteral nutritional infusion Rationale: A complication of a subclavian central line can be an embolism resulting from air or thrombus. A sudden onset of chest pain shortly after the initiation of parenteral nutrition may mean that this complication has developed. The central line is clamped, not discontinued, and the primary health care provider is notified immediately. Option 1 is an appropriate action but not the first action. Option 3 is not a priority because the client's symptoms do not indicate the presence of hypoglycemia or hyperglycemia. The primary health care provider will probably prescribe an ECG, but this action would not be the initial action in this situation.

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? "This diet will help lower my blood pressure" "The reason I need to lower salt intake is to reduce fluid retention" "This diet is not a replacement for my antihypertensive medication" "Canned foods are inexpensive and are good to use on a low-sodium diet"

"Canned foods are inexpensive and are good to use on a low-sodium diet" Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Any commercial food that contains preservative is a significant source of sodium. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Canned foods use salt as a preservative and should not be encouraged as part of a low-sodium diet.

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? Food preferences Cultural preferences Presence of bowel sounds Dentition and ability to chew

Dentition and ability to chew Rationale: It may be necessary to modify a client's diet to a soft or mechanical chopped diet if the client has difficulty chewing. Food and cultural preferences should have been determined on admission. Bowel sounds should be present before introducing any diet to a postoperative client.

The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicate an understanding of the procedure? "The stoma needs to be cleaned with only water" "The best time to change the appliance is at night" "The pouch needs to be changed every 5 to 7 days" "I'll cut the skin barrier 10 millimeters larger than the stoma"

"The pouch needs to be changed every 5 to 7 days" Rationale: Clients with urinary diversions need to be educated on the proper care of the urinary stoma. An appliance with an attached collection bag is placed over the stoma to collect urine. The most ideal time to change the appliance is in the morning, not at night. The stoma needs to be cleaned with both non-residual soap and water, not just water. The skin barrier is cut no more than 3 millimeters larger than the stoma to prevent urine leakage and irritation of the exposed skin. The pouch needs to be changed every 5 to 7 days.

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? 100 calories 500 calories 1000 calories 1500 calories

1000 calories Rationale: The amount of weight loss in a client in a weight loss program is based on food intake, energy expenditure, and fluid loss. To obtain a weight loss of 1 pound per week the client needs a decrease in daily caloric intake of 500 calories. To lose 2 pounds per week the client needs to decrease intake by 1000 calories per day.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What would the nurse do? Select all that apply. Hold the feeding Document the amount of residual Place it into a container for laboratory analysis Reinstill the residual and administer the feeding Deduct the amount of the residual from the new feeding before administering

Document the amount of residual Reinstill the residual and administer the feeding Rationale: Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL is reinstilled; then a normal amount of prescribed tube feeding is administered. The amount of residual should be documented. It is important to return the contents to the stomach to prevent electrolyte imbalances. The feeding is not held, and the residual is not sent to the laboratory. The tube feeding should continue at the prescribed rate.

A hospitalized client is a lacto-vegetarian. Which food item would the nurse remove from the meal tray? Eggs Milk Cheese Broccoli

Eggs Rationale: Lacto-vegetarians eat milk, cheese, and dairy foods but avoid meat, fish, poultry, and eggs.

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 Beans Cereal Oranges Chicken Broccoli

Eggs Chicken Rationale: Complete/high-quality proteins are proteins that contain all essential amino acids and are found in a variety of meats, eggs, and dairy products. Beans are incomplete/lower-quality proteins as are some cereals. Oranges and broccoli contain vitamins and minerals and minimal protein.

The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would be the nurse obtain? A straight catheter A Coudé tip catheter A triple-lumen catheter A double-lumen catheter

A triple-lumen catheter Rationale: Straight catheters are used for intermittent catheterization. Double-lumen catheters are used for indwelling urinary catheterization in which one lumen drains urine in the bladder and the other lumen is used to inflate and deflate the balloon. Triple-lumen catheters are used for continuous bladder irrigation or bladder medication instillation. One lumen is to inflate and deflate the balloon, another lumen is to drain urine and the irrigation solution, and the other lumen instills the irrigation solution into the bladder. A Coudé tip catheter is a catheter with a curved tip at the end used to advance the catheter past a hypertrophied prostate, in which using a standard catheter would be difficult.

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. Tea Fish Cocoa Coffee Chicken

Fish Chicken Rationale: Foods naturally high in phosphates should be avoided with hyperphosphatemia. These include fish, chicken, eggs, milk products, vegetables, whole grains, and carbonated beverages. Coffee, tea, and cocoa are not high in phosphates.

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? Rice and fish Eggs and bacon Oatmeal and milk Hamburger and oranges

Hamburger and oranges Rationale: The client with tuberculosis often is malnourished and needs dietary support to recover while receiving treatment. Food sources that are rich in protein include meats and legumes. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens.

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure? Instilling 500 to 1000mL of lukewarm tap water through the stoma Advises the client to hold the breath if cramping occurs during installation of the solution Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamps the tubing to allow the solution to flow into the stoma

Instilling 500 to 1000mL of lukewarm tap water through the stoma Rationale: Clients with sigmoid colostomies may require irrigation of the stoma to promote regular colon emptying. Irrigation is performed by instilling 500 to 1000 mL of lukewarm tap water through the stoma and then allowing the irrigation solution and stool to drain into a collection bag. The nurse hangs the irrigation solution so that the bottom of the bag is level with the client's shoulder. The nurse inserts the irrigation tube without force into the stoma and unclamps the tubing to allow the solution to flow into the stoma. The nurse would clamp the tubing if cramping occurs and then resume the instillation as tolerated.

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? Maltose Lactose Sucrose Fructose

Lactose Rationale: Several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as these in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the primary health care provider. This will resolve the client's symptoms and promote adequate nutrition for the client.

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. Eggs Bread Lettuce Potatoes Avocados Salt substitute

Potatoes Avocados Salt substitute Rationale: Potatoes and avocados are potassium-containing foods and should be avoided if on a potassium-restricted diet. Salt substitute, often potassium chloride used in place of regular salt (sodium chloride), is a source of potassium. Eggs, bread, and lettuce are all foods low in potassium and are allowed in a potassium-restricted diet.

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 Calcium Vitamin C Vitamin K Unsaturated fats

Protein Vitamin C Rationale: Protein is needed to build new tissues and vitamin C is active in the body in many enzyme processes and with collagen synthesis. A client with a large abdominal wound will require adequate protein and vitamin C intake to heal.

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. Apples Raisins Kiwifruit Bananas Pineapples Canned peaches

Raisins Kiwifruit Bananas Rationale: Foods that are high in potassium include bananas, cantaloupe, kiwifruit, oranges, and dried fruits such as raisins. Fruits low in potassium include apples, cherries, grapefruit, canned peaches, pineapple, and cranberries.

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 would be to explain that the primary health care provider is concerned about which phenomenon? Dehydration Hypokalemia Hypernatremia Rebound hypoglycemia

Rebound hypoglycemia Rationale: Clients receiving total parenteral nutrition are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before discontinuing the parenteral nutrition, the body must adjust to the lowered glucose levels. If the total parenteral nutrition were suddenly withdrawn, the client would probably have rebound hypoglycemia. Dehydration, hypokalemia, and hypernatremia are not concerns when the parenteral nutrition is discontinued.

The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumsized male client. Which action by the new graduate nurse would indicate a need for further teaching? Cleans the catheter proximally to distally with soap and water Maintains the urinary collection bag below the level of the bladder Removes a loose catheter anchor and places a new anchor on the shin Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position

Removes a loose catheter anchor and places a new anchor on the shin Rationale: Routine catheter care is imperative in the prevention of catheter-associated urinary tract infections (CAUTIs). Meticulous technique needs to be used to prevent the introduction of microorganisms to the urinary tract. For uncircumcised males, the nurse would retract the foreskin to inspect the urethral meatus for skin irritation and then cleanse the site with warm soapy water and return the foreskin to its normal position. The catheter tubing needs to be cleaned in a proximal to distal direction. The urinary drainage bag needs to be maintained below the level of the bladder to prevent reflux of urine into the urinary tract. Any loose anchors need to be removed and replaced to ensure the catheter tubing does not get pulled on, as this could cause trauma to the urethra. However, the anchor needs to be placed on the upper thigh, not the shin. Therefore, option 3 is the action that requires a need for further teaching.

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. Fish Rhubarb Spinach Cabbage Sauerkraut American Cheese

Sauerkraut American cheese Rationale: The client's laboratory value reflects hypernatremia because the normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Based on this finding, the nurse should instruct the client to avoid foods high in sodium. Sauerkraut and American cheese are high in sodium content. These should include foods from animal sources, which contain physiological saline, and highly processed meats and other foods that often have sodium added as a preservative.

The nurse is providing dietary instructions to a client with gout. The nurse would tell the client to avoid which food item? Scallops Chocolate Cornbread Macaroni Products

Scallops Rationale: Scallops should be omitted from the diet of a client who has gout because of the high purine content. The food items identified in the remaining options have negligible purine content and may be consumed by the client with gout.

The nurse is inserting an indwelling urinary catheter in a client and begins to inflate the balloon when the client starts complaining of pain. Which action would the nurse take? Continue to inflate the balloon Deflate the balloon, slightly withdraw the catheter and attempt to reinflate the balloon Deflate the balloon, completely withdraw the catheter and end the procedure to notify the primary health care provider Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon.

Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon. Rationale: The client's pain during inflation of the balloon may be related to the urinary catheter tip being located in the urethra and not the bladder. If the client begins to complain of pain with the inflation of an indwelling urinary catheter balloon, the nurse would allow the fluid injected into the balloon to drain back into the syringe attached to the balloon inflation port. Then, the nurse would advance the catheter further into the urethra to the bladder and then attempt to inflate the balloon.

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 impairs pancreatic function and insulin production TPN increases the cortisol levels, which causes hyperglycemia TPN increases the risk for infection, which raises the blood glucose TPN contains concentrated carbohydrates and raises blood glucose

TPN contains concentrated carbohydrates and raises blood glucose Rationale: TPN contains a high concentration of glucose and also amino acids, which are proteins. With a continuous infusion, the body does not produce enough insulin to use the glucose effectively. The glucose is monitored usually around the clock if the client is not eating. Fast, or rapid-acting, insulin is administered according to the client's capillary blood glucose level. TPN does not impair pancreatic function or raise cortisol levels. TPN does increase the risk for infection, which often raises glucose levels, but there is no actual infection.

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? A dietary diary Food preferences The presence of food allergies Medical history of conditions related to nutritional status

The presence of food allergies Rationale: The presence of food allergies is critical to know before developing a nutritional plan. Dietary diary results, food preferences, and medical history provide good information but are not as crucial as the presence of food allergies.

The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items would the nurse encourage? Select all that apply. Milk Tofu Cheese Broccoli Sardines Mustard greens

Tofu Broccoli Sardines Mustard greens Rationale: Lactose-intolerant clients should not eat dairy products. Therefore, these clients need high-calcium foods from nondairy sources. Tofu, broccoli, mustard greens, and sardines are foods that are high in calcium that do not come from dairy sources. Although milk and cheese are high in calcium, they are dairy products, which lactose-intolerant clients need to avoid.

A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? Prone position Lithotomy position Left lateral Sim's position Right lateral Sim's position

left lateral Sim's position Rationale: For digital removal of stool, the client would be placed in the left lateral Sims' position, as this follows the anatomical curvature of the colon.

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse would tell the client to select which food item that is high in riboflavin? Milk Tomatoes Citrus Fruits Green, leafy vegetables

Milk Rationale: Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid.

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. Fish Yogurt Potatoes Chicken White bread Cottage cheese

Yogurt Cottage cheese Rationale: Osteoporosis is a chronic metabolic disease in which there is bone loss resulting in decreased bone density and increased risk for fracture. Calcium intake is important to minimize the risk of osteoporosis. The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium also may be added to certain products, such as orange juice, which are then advertised as being "fortified" with calcium. Calcium supplements are also recommended to minimize the risk of osteoporosis. Fish, potatoes, chicken, and white bread are foods that are not high in calcium.