a nurse is planning care for a client who is postoperative following a liver transplant and weighs 65 kg which of the following actions should the nur
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Nursing Elites

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1. A client who is postoperative following a liver transplant and weighs 65 kg. Which of the following actions should the nurse plan to take?

Correct answer: C

Rationale: After a liver transplant, it is crucial to stress the importance of safe food-handling practices to prevent foodborne illnesses, especially due to the client's altered immune system. Keeping the client NPO for the first week postoperative is not recommended as early nutrition support is essential for recovery. Limiting caloric content once the client resumes eating may not be appropriate as they need adequate nutrition for healing. Decreasing foods high in carbohydrates without a specific indication may lead to inadequate nutrient intake, which is not ideal for the client's recovery.

2. What nursing diagnosis would be most appropriate for a patient with heart failure?

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

3. Which of the following foods or beverages would offer the most nutrients per calorie?

Correct answer: D

Rationale: Broccoli is indeed the correct answer. Broccoli is considered nutrient-dense, meaning it provides a significant amount of essential nutrients like vitamins, minerals, and fiber while being relatively low in calories. On the other hand, choices A, B, and C are not as nutrient-dense as broccoli. Chicken can be nutritious but may vary in nutrient content depending on the cut and preparation method. Wine, although containing antioxidants like resveratrol, is not a significant source of essential nutrients. White bread is often low in nutrients and fiber compared to whole grain options, making it less nutrient-dense than broccoli.

4. The nurse understands that malnutrition is a prevalent issue among hospitalized individuals. What is it commonly associated with?

Correct answer: D

Rationale: Malnutrition is often associated with a weakened immune system. This is because when the body is not sufficiently nourished, it lacks the necessary nutrients to maintain a well-functioning immune system, making patients more vulnerable to infections and other health complications. This can potentially increase mortality rates and prolong hospital stays, contrary to choice C. Choices A and B are incorrect as malnutrition does not lead to decreased health care costs or high blood pressure. In fact, it may increase health care costs due to the potential for increased complications and extended hospital stays.

5. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

Correct answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

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