A nurse is caring for a client who has stomatitis following radiation treatment. Which of the following is an appropriate intervention for the nurse to take?

Correct Answer: B

Rationale: In caring for a client with stomatitis following radiation treatment, offering mouth rinses with normal saline and water (Option B) is the most appropriate intervention. This intervention helps to clean the oral cavity, soothe inflamed tissues, and promote healing. Normal saline has a gentle cleansing effect without causing further irritation, making it a safe and effective choice for oral hygiene in this situation. Option A, serving foods without sauces or gravies, is incorrect because these types of foods may be irritating to the inflamed oral tissues and can worsen discomfort. Option C, serving hot foods, is also inappropriate as heat can exacerbate the client's symptoms and should be avoided. Option D, instructing the client to drink liquids without a straw, is not directly related to managing stomatitis and does not address the specific needs of the client in this situation. Educationally, it is crucial for nurses to understand the principles of managing stomatitis, especially in clients undergoing radiation treatment. Providing evidence-based care, like using normal saline mouth rinses, demonstrates the nurse's competency in promoting oral health and comfort for clients experiencing stomatitis. By selecting the appropriate intervention, nurses can contribute to better outcomes and quality of life for their clients undergoing radiation therapy.

Correct Answer: C

Rationale: In teaching a client with chronic kidney disease about nutrition, it is crucial to emphasize limiting protein intake. The correct answer is C) Limit protein intake. This recommendation is essential because impaired kidney function in chronic kidney disease leads to a reduced ability to clear waste products from protein metabolism, resulting in a buildup of uremic toxins. Therefore, reducing protein intake can help lessen the workload on the kidneys and slow the progression of kidney disease. Option A) Increase phosphorus intake is incorrect because in chronic kidney disease, there is difficulty excreting phosphorus, leading to hyperphosphatemia, which can contribute to bone and mineral disorders. Option B) Limit calcium intake is incorrect because while calcium levels may need monitoring in kidney disease, a blanket limitation is not recommended as it can lead to other complications such as bone disorders. Option D) Increase potassium intake is incorrect as hyperkalemia is a common concern in kidney disease, and increasing potassium intake can further exacerbate this electrolyte imbalance. In an educational context, it is vital for nurses to understand the rationale behind dietary recommendations for clients with chronic kidney disease to effectively educate and support them in managing their condition and promoting overall health and well-being. By providing evidence-based nutritional guidance, nurses can empower clients to make informed decisions about their diet and lifestyle to optimize their kidney function and quality of life.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Prealbumin. Prealbumin is a valuable marker for assessing a client's nutritional status because it has a shorter half-life compared to other lab values like albumin. Prealbumin levels reflect recent protein intake and can help determine if the TPN therapy is providing adequate nutrition to support wound healing and metabolic needs in a client with major burn injuries. Option A) Iron, is not the priority lab test in this case because iron levels are more indicative of anemia and not a direct marker of nutritional adequacy in this context. Option B) Magnesium is important for various metabolic functions, but it is not the most specific lab test to assess nutritional status in a client receiving TPN for major burn injuries. Option C) Folic acid is essential for cell division and growth, but its levels may not necessarily reflect the current nutritional status of a client receiving TPN for major burn injuries. Educationally, understanding the significance of monitoring prealbumin levels in critically ill patients, especially those with major burn injuries, is crucial for nurses to provide optimal care and ensure adequate nutritional support for healing and recovery. Regular monitoring of prealbumin levels can guide healthcare providers in adjusting TPN formulations and other nutritional interventions to meet the client's needs effectively.

Correct Answer: C

Rationale: In this scenario, option C is the correct answer. The statement "I will limit my daily sodium intake to 3 grams" indicates that the client understands the teaching about a heart-healthy diet for hypertension. Excessive sodium intake can lead to increased blood pressure, so limiting sodium is crucial for managing hypertension. Option A is incorrect because getting 15% of total daily calories from saturated fats is not heart-healthy. Saturated fats can contribute to elevated cholesterol levels and increase the risk of heart disease. Option B is also incorrect because decreasing potassium in the diet is not recommended for hypertension management. Potassium is essential for regulating blood pressure and muscle function. Option D is incorrect because while eating fruits is generally healthy, the specific quantity mentioned may not be necessary or appropriate for managing hypertension. Educationally, it's important for nurses to teach clients about the impact of different nutrients on their health conditions. Understanding the role of sodium, potassium, and saturated fats in hypertension can empower clients to make informed dietary choices to better manage their condition and overall health.

Correct Answer: D

Rationale: In the case of a client with bulimia nervosa, electrolyte imbalances are a common concern due to purging behaviors. The correct answer is option D) Potassium 3.2. A potassium level of 3.2 is significantly below the normal range (3.5-5.0 mEq/L) and can lead to serious cardiac complications such as arrhythmias and cardiac arrest. Hypokalemia is a common finding in individuals with bulimia due to excessive vomiting or laxative abuse, which can lead to potassium depletion. Option A) White Blood Cells 5,200/mm3 is within the normal range (4,500-11,000/mm3) and is not typically affected by bulimia nervosa. Option B) Hemoglobin 14 is also within the normal range (12-16 g/dL) and is not a priority concern in this context. Option C) Magnesium 1.6 is low, but potassium is a more critical electrolyte to monitor in clients with bulimia nervosa. Hypomagnesemia is common in eating disorders but does not pose the same immediate risk as severe hypokalemia. Educationally, understanding the importance of monitoring electrolyte levels in clients with eating disorders is crucial for nurses. Recognizing the significance of abnormal laboratory values and their potential impact on the client's health allows for timely intervention and prevention of complications. By prioritizing potassium monitoring in this scenario, the nurse demonstrates clinical judgment and promotes patient safety.