A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the
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A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) - Answer>>> Snack of potato chips, and diet soda.
Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
Breakfast of eggs, bacon, toast, and coffee.
Bedtime snack of crackers and milk.
The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond? - Answer>>> Obtain a blood glucose reading
Rationale:
The signs of hypoglycemia and hyperglycemia may be difficult to distinguish. Weakness, headache, and blurred vision can occur in either blood glucose alteration. A blood glucose reading will assist in confirming the diagnosis so that the appropriate action can be taken. Option 3 would be implemented if the child had hypoglycemia. Option 4 is inappropriate because the child should eat meals at basically the same time each day to achieve the best diabetic control. Contacting the health care provider would not be the immediate action; however, the nurse should inform the registered nurse of the situation.
A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply. - Answer>>> Cool to touch
Swelling at the site
May not have a blood return
Rationale:
An infiltrated IV is one that has dislodged from the vein, and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line. The other options indicate phlebitis.
The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside? - Answer>>> Suction equipment
Rationale:
In a postoperative client, a concern related to initiating a diet is aspiration. Initiating postoperative oral fluids may lead to distention and vomiting. Suction equipment must be available. A blood pressure cuff may be necessary but is not the priority from the options provided. A code cart is unnecessary. A straw may help the client sip fluids but is not necessary.
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