NR-228 Nutrition, Health & Wellness - Set 5 - Part 3

Correct Answer: Give four ounces of regular soda

An alert client with a glucose below seventy needs fifteen grams of fast acting carbohydrate, and four ounces of regular soda supplies exactly that. The nurse then waits fifteen minutes and rechecks the glucose. Option a is incorrect because peanut butter adds fat and protein that delay gastric emptying and slow the rise in glucose. Crackers with peanut butter belong after the glucose recovers, not as the emergency treatment. Option b is incorrect because glucagon is reserved for a client who cannot swallow safely or is unresponsive. This client is awake and protecting the airway, so oral carbohydrate works faster and carries no injection risk. Option d is incorrect because calling the provider delays treatment of a falling glucose that can cause seizure within minutes. The nurse treats the hypoglycemia under the standing protocol and reports the episode afterward.

Correct Answer: Measure the blood pressure immediately

A severe occipital headache in a client taking an MAOI signals hypertensive crisis. Obtaining the blood pressure confirms the emergency and directs the next steps, which are stopping intake and notifying the provider. Option a is incorrect because an analgesic treats the symptom while a dangerous blood pressure rise continues unrecognized. The headache here is a warning of possible intracranial bleeding, not ordinary head pain. Option c is incorrect because positioning does nothing to address a norepinephrine surge, and lying flat may worsen cerebral pressure. Assessment must come before any comfort measure in a suspected crisis. Option d is incorrect because delaying reassessment wastes time during a medical emergency that can progress to intracranial hemorrhage. Fluids neither lower the pressure nor remove tyramine already absorbed from the meal.

Correct Answer: Increased bleeding risk around the surgery

Ginkgo, garlic and ginger all raise bleeding risk, and aspirin adds antiplatelet effect on top. These products are stopped before surgery and used cautiously with anticoagulants and antiplatelet drugs. Option a is incorrect because sedation is not the hazard these three herbs share. Their common problem is platelet and clotting interference, which becomes dangerous in an operative field rather than in the airway. Option b is incorrect because these herbs push in the same direction as aspirin instead of opposing it. The effects add together, so bleeding becomes more likely rather than antiplatelet action being lost. Option d is incorrect because hypoglycemia belongs to ginseng taken alongside antidiabetic medication, and none of the listed products is ginseng. Nothing on this client's form points toward a falling glucose level.

Correct Answer: Holding the tray until thirty minutes pass

Levothyroxine is taken on an empty stomach thirty to sixty minutes before breakfast, because food, calcium, iron and coffee all reduce absorption. Delivering and timing a tray is within the assistive role. Option a is incorrect because client education is a licensed nursing responsibility and cannot be handed off. Assistive personnel may reinforce a point already taught, but the initial teaching belongs to the nurse. Option c is incorrect because judging whether a beverage may be given requires clinical reasoning about absorption. Coffee reduces levothyroxine uptake, and that determination stays with the nurse rather than the aide. Option d is incorrect because assessment may not be delegated under any circumstance. Judging whether hormone replacement is adequate calls for nursing evaluation of the client's overall response to therapy.

Correct Answer: Begin a low fat solid diet now

Early feeding within twenty four to forty eight hours lowers infectious complications, and a low fat solid diet once symptoms improve is preferable to starting with clear liquids. Prolonged gut rest causes mucosal atrophy. Option b is incorrect because prolonged fasting to rest the pancreas is the old model and is now cautioned against. Starving the gut thins the mucosa and allows bacteria to translocate across it. Option c is incorrect because intravenous feeding is held back for clients who cannot tolerate enteral intake after five to seven days. This client is tolerating oral intake, so a central line is unnecessary. Option d is incorrect because clear liquids delay adequate nutrition and are not required as an intermediate step. Lipase, not amylase, is the more specific enzyme, and diet advancement follows symptoms rather than laboratory values.

Correct Answer: Cachexia, which nutrition support cannot fully reverse

Cachexia is cytokine and tumor driven muscle loss that continues despite adequate intake and cannot be fully reversed by conventional nutrition support. Loss above five percent over six months meets the diagnostic criterion. Option a is incorrect because anorexia means appetite loss and improves when the client is fed. This client is eating well and taking supplements, yet skeletal muscle continues to disappear. Option b is incorrect because fluid loss produces a rapid change over days, not a steady decline across four months. Visible loss of lean tissue points to catabolism rather than to a shifting water balance. Option c is incorrect because enzyme replacement corrects maldigestion, which presents with fatty, foul stools and would respond to treatment. Nothing here suggests steatorrhea, and the weight loss persists despite good intake.

Correct Answer: Reactive hypoglycemia from an oversized insulin surge

Rapid delivery of carbohydrate to the jejunum produces fast absorption and an oversized insulin response. The glucose load clears quickly while insulin persists, so blood sugar falls one to three hours after eating. Option a is incorrect because the osmotic shift drives early dumping, which arrives within ten to thirty minutes and brings cramping, bloating and flushing. Hunger and confusion two hours later point elsewhere. Option c is incorrect because bacterial overgrowth causes bloating, flatulence and steatorrhea that persist rather than peaking and resolving with food. Relief after a few crackers is not a feature of overgrowth. Option d is incorrect because loss of intrinsic factor after gastrectomy produces fatigue, pallor, glossitis and paresthesias over months. Those findings develop slowly and have no link to the timing of a meal.

Correct Answer: Sodium limited to two grams each day

Ascites is driven by sodium and water retention from activation of the renin angiotensin aldosterone system, so sodium restriction near two grams daily is the dietary cornerstone. Fluid is not restricted while serum sodium is normal. Option a is incorrect because fluid restriction is reserved for dilutional hyponatremia, conventionally a serum sodium below about one hundred twenty five. This client has a normal level, so limiting water adds no benefit. Option b is incorrect because cirrhosis is a wasting illness in which protein needs rise rather than fall. Guidelines set intake at one point two to one point five grams per kilogram daily. Option c is incorrect because potassium is monitored rather than routinely restricted here, and spironolactone retains it while furosemide wastes it. The mineral that drives fluid accumulation in ascites is sodium.

Correct Answer: Baked chicken with white rice and applesauce

A low fiber diet during recovery uses refined grains and tender protein with fruit that has no skin or seeds. Baked chicken, white rice and applesauce leave little residue for the inflamed segment to move. Option a is incorrect because bran is among the highest fiber foods in common use and an unpeeled pear adds more. Both belong to the later phase once inflammation has fully resolved. Option b is incorrect because legumes are a concentrated fiber source and a whole wheat tortilla adds still more. Neither is appropriate while the colon wall is inflamed and possibly microperforated. Option d is incorrect because lentils and raw salad vegetables carry heavy insoluble fiber and demand vigorous colonic work. Cooked, peeled and seedless choices are what the inflamed segment can tolerate now.

Correct Answer: A central venous catheter such as a PICC

Solutions above nine hundred milliosmoles per liter require central venous access. The high flow of a central vein dilutes the admixture almost instantly, while a peripheral vessel would be injured and develop thrombophlebitis. Option b is incorrect because catheter gauge does not change the osmolarity the vessel wall must tolerate. A hypertonic solution pulls water from endothelial cells regardless of how wide the cannula is. Option c is incorrect because a midline ends in a peripheral vein and carries the same nine hundred milliosmole ceiling. It provides longer dwell time, not the dilution that a concentrated admixture requires. Option d is incorrect because a hand vein is small, thin walled and slow flowing, the worst possible site for a concentrated infusion. Painful, cord like thrombophlebitis would follow quickly.