FOUNDATIONS EXAM 1 - UNSURE Q'S

A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145 lb

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?

Blood from the fingertips shows changes in glucose more quickly than other testing sites.

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what?

Cut the nail straight across.

The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition? Potassium Sodium Magnesium Iodine

Iodine

The nurse is teaching a new mother who had decided to breast-feed her infant. What nutrient must be supplemented by the mother after the first four months of breast feeding?

Iron

What dual purpose does an audit serve? (ch. 16) Communication and evaluation Knowledge and quality Education and confidentiality Quality assurance and reimbursement

Quality assurance and reimbursement

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:

RDA level

To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to: eliminate high-fiber foods, eat foods high in folic acid. consume saturated fats. consume milk products in the last trimester.

eat foods high in folic acid.

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of: positive nitrogen balance. anabolism. negative nitrogen balance. digestion.

negative nitrogen balance.

A client who is taking supplements complains of severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:

niacin

Child development ages

3 months may be able to lift head but not expected 6-9 months something 15 months walk unassisted 3 years stack blocks

The nurse is caring for four clients. Which does the nurse identify as highest risk for development of cardiometabolic syndrome?

36-year old with obesity who smokes

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate? Orthodox Jews: Grilled shrimp Hindus: Vegetable plate Mormons: Toast with coffee Orthodox Jews: Grilled pork chop

Hindus: Vegetable plate

Which vitamin is found only in animal foods?

Vitamin B12

A nurse is caring for a client who reports frequent nausea. Which food should the nurse recommend to the client when the nausea is relieved?

clear fruit juices

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor? "Colorectal cancer is not as common in vegetarians compared to people who eat high fat diets." "Protein complementation is important to help the client get the needed amino acids." "Semi-vegetarians exclude red meat from their diet and seek protein elsewhere." "According to research, vegetarians have a higher incidence of obesity than others."

"According to research, vegetarians have a higher incidence of obesity than others."

The nurse is helping a client perform oral hygiene. When asked whether the client flosses, the client states, "I don't like to floss because it makes my gums bleed." What is the appropriate nursing response? (Select all that apply.)

"Flossing removes plaque and food debris that a toothbrush may miss." "The chance of tooth and gum disease can be reduced by flossing."

A client informs the nurse that they have been following a strict low calorie diet and skipping meals to lose weight faster. The client reports feeling upset about not losing any weight and wants to know what to do. What is the best response by the nurse? "If you keep cutting out a lot of calories, you will lose weight." "The body will go into starvation mode by slowing metabolic rate and it will be hard to lose weight." "Are you sure you are cutting back as much as you say you are? You should be losing weight." "Losing weight is hard and sometimes no matter what you do, it doesn't work."

"The body will go into starvation mode by slowing metabolic rate and it will be hard to lose weight."

A nurse is inserting a nasogastric tube in a client with an ileus. Which actions would be appropriate for the nurse to use to confirm correct placement of the tube? Select all that apply. Auscultate injected air over the epigastric space. Aspirate stomach contents to check pH level. Do a radiographic examination. Measure tube length and tube marking. Listen for gurgling at the end of the nasogastric tube.

Aspirate stomach contents to check pH level. Do a radiographic examination. Measure tube length and tube marking.

Which nursing action associated with successful tube feedings follows recommended guidelines? Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. Prevent contamination during enteral feedings by using an open system.

Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? (ch. 16) Inform the health care provider that a written order is needed. Write the order in the client's record. Call the pharmacy to have the order entered in the electronic record. Add the new order to the medication administration record. (ch. 16)

Inform the health care provider that a written order is needed.

A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support? Low serum albumin levels Proteinuria Low random blood glucose levels Increased white blood cells

Low serum albumin levels

During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her 6-month-old infant. What does the nurse inform the mother? New foods should be introduced one at a time for a period of 5 to 7 days. It is too early to add solid foods to the infant's diet. A new solid food should be introduced daily to the infant's diet for a week. Adding solid foods is fine at this age, but avoid iron-fortified foods.

New foods should be introduced one at a time for a period of 5 to 7 days.

Which characteristic of a nurse's charting will assist most in the avoidance of errors? (ch. 16) Detail Brevity Subjectivity Timeliness

Timeliness

Which nutrient does the nurse identify as appropriate for a client with a normal dietary order who is consuming 2000 calories daily?

Total fat less than 65 g, sodium less than 2400 mg, saturated fat less than 20 g, cholesterol less than 300 mg

Which of the following is a fat-soluble vitamin? Vitamin C Vitamin B12 Vitamin E Vitamin B6

Vitamin E

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching? "My body does not make its own vitamins." "Cooking can change the vitamin contents in foods." "I drink orange juice fortified with added calcium." "My husband and I are ordering a product that has megadoses of vitamins."

"My husband and I are ordering a product that has megadoses of vitamins."

A grandmother visits the pediatric clinic with her daughter and 18-month-old granddaughter. The grandmother states, "I told my daughter she needs to get that baby potty trained. She is too old to be messing in her pants." What is the best response the nurse can make?

"You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained."

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate? Allow the client privacy during mealtime. Delegate feeding assistance to the unlicensed assistive personnel. Assess when client generally eats meals. Contact the healthcare provider to prescribe an appetite stimulant.

Assess when client generally eats meals.

A nurse is caring for a client who has a decrease in appetite. Which actions by the nurse would be appropriate?

Assist with oral hygiene

The nurse is preparing to provide hygiene for a client who has a leg cast and activity restrictions. Which is the priority nursing intervention that will be performed to prepare for hygiene care?

Check the nursing care plan for hygiene directives.

A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake? Encourage the client to eat in the dining room. Feed the client their meal while in bed. Allow the client to eat when they want to. Discourage family from visiting during meals.

Encourage the client to eat in the dining room.

The nurse identifies the correct steps for removal of a nasogastric tube. Place the steps in order.

Identify the client. Raise bed to 30 to 45 degrees. Put on nonsterile gloves. Discontinue suction. Remove tube while client holds breath.

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube? Use a small syringe and insert 10 mL of air. If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. Continue to instill air until fluid is aspirated. Place the client in the Trendelenburg position to facilitate the fluid aspiration process.

If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? (ch. 16) It documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.

It provides quick access to abnormal findings.

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method? (ch. 16) Source-oriented method PIE charting method Problem-oriented method Focus charting method

Problem-oriented method

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? (ch. 16) Subjective data should be included when documenting. Objective data is what the client states about the problem. The plan includes interventions, evaluation, and response. Abnormal laboratory values are common items that are documented.

Subjective data should be included when documenting.

The nurse is reviewing a client's laboratory report. The report indicates the client's albumin level is 2.89 g/L (4.19 mmol/L). Which inference can the nurse make about the laboratory result?

The client has malnutrition. Serum albumin values reflect protein intake or absorption. Values of less than 3.5 g/dL (5 mmol/L) may indicate nutritional deficits and malnutrition or malabsorption.

A nurse is conducting client education with a woman who meets the diagnostic criteria for metabolic syndrome. The nurse is teaching the client about the MyPlate tool for promoting healthy food intake. According to MyPlate, the highest proportion of food in each meal should consist of what? Dairy Protein Unsaturated fats Vegetables

Vegetables

A client has a history of long-term alcohol abuse. Which of the following nutrients would need to be required in increased amounts?

Vitamin B

A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin? Vitamin C Vitamin B12 Folic acid Vitamin A

Vitamin B12

The nurse is caring for a client who has been experiencing prolonged wound healing from a surgical procedure. A deficiency in which nutrient would be associated with this condition?

Vitamin C

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient? Calcium Vitamin K Potassium Vitamin C

Vitamin K

When planning interventions in the immediate hours after birth the nurse recognizes the need to provide an injection of which vitamin (to manage a lack of it), due to lack of bacteria in the intestinal tract?

Vitamin K

Which client's laboratory data indicates the need to include interventions in the nursing plan of care specifically aimed at cardiac and vascular disease?

total serum cholesterol of 180 mg/dL; HDL 32 mg/100 mg/dL