Ch 35: Nutrition
At what period of life do nutrient needs stabilize? a) Infancy b) Adulthood c) Adolescence d) Pregnancy
Adulthood Explanation: Nutrient needs change across the life span in relation to growth, development, activity, and age. Periods of intense growth and development (such as during infancy, adolescence, pregnancy and lactation) increase nutrient needs. Nutrient needs stabilize during adulthood.
A nurse documents a client's hemoglobin as 8 g/dL. What nutritional condition does this biochemical data signify? a) Malnutrition b) Dehydration c) Anemia d) Malabsorption
Anemia Explanation: If hemoglobin (normal = 12 to 18 g/dL) is decreased, anemia is present. A increased hematocrit signifies dehydration. Malnutrition is related to serum albumin, blood urea nitrogen, and creatinine. Decreased serum albumin also signifies malabsorption.
A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching? a) Glucose levels will decrease with illness and stress. b) Blood from the fingertips shows changes in glucose more quickly than other testing sites. c) Calibrate the glucose meter every six months. d) Use a forearm sample with signs and symptoms of hypoglycemia.
Blood from the fingertips shows changes in glucose more quickly than other testing sites. Explanation: With glucose monitoring, blood from the fingertips shows changes in blood glucose more quickly than other testing sites. With signs and symptoms of hypoglycemia, a fingertip site should be used. Calibrate the glucose monitors at least every month. Glucose levels increase with illness and stress to the body.
After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat? a) Cream of wheat, cranberry juice, and milk b) Fat-free broth, ginger ale, and custard c) Clear broth, hot tea, and yogurt d) Bouillon, apple juice, and gelatin
Bouillon, apple juice, and gelatin Explanation: Clear liquid diets contain foods that are clear liquids at room temperature or body temperature, such as gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. Full liquid diets contain all the items on a clear liquid diet, but also include milk and milk drinks, custards, puddings, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes.
A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client? a) Make fruits and vegetables at least half of total food intake. b) Drink nonfat or 1% milk. c) Eat a variety of enjoyable foods, but less quantity. d) Drink juice for majority of fluid intake.
Drink juice for majority of fluid intake. Explanation: Water should comprise the majority of fluid intake. The remainder should come from food sources such as fruit or 100% fruit juices.
Which nursing action associated with successful tube feedings follows recommended guidelines? a) Prevent contamination during enteral feedings by using an open system. b) Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. c) Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. d) Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.
Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. Explanation: The nurse should check the residual before each feeding or every 4 to 8 hours during a continuous feeding. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia. A closed system is the best way to prevent contamination during enteral feedings. The bowel sounds do not have to be assessed as often as 4 times per shift. Once a shift is sufficient. Food dye should not be added as a means to assess tube placement or potential aspiration of fluid.
A nurse is teaching an adolescent client about nutrition following a hospital admission. What should the nurse understand about adolescent nutrition? a) Childhood nutrition problems may worsen during adolescence. b) Nutritional needs decrease during adolescence. c) Adolescents tend to eat meals at home. d) Adolescents eat their food slowly.
Childhood nutrition problems may worsen during adolescence. Explanation: Adolescents may have childhood nutrition problems worsen during this period. During puberty, nutritional needs increase to support growth. Adolescents tend to eat away from home in fast-food places, leading to poor nutrition practices. Another characteristic of adolescence is eating quickly, therefore leading to overeating.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which action should the nurse perform with TPN? a) Change transparent dressings every day. b) Discard unused TPN every 24 hours. c) Monitor blood glucose levels every 12 hours. d) Check vital signs every 8 hours.
Discard unused TPN every 24 hours. Explanation: With TPN, any unused portion should be discarded every 24 hours. Vital signs with TPN should be checked every 4 hours. Blood glucose should be checked every 6 hours. If the client has a transparent dressing on the central venous access, it can be changed weekly.
A Hispanic client is being placed on a low-sodium diet. What approach by the nurse would be most effective to increase dietary compliance? a) Contact the health care provider to change the diet order b) Explain to the client that most ethnic foods must be avoided. c) Tell the client to follow the diet to the best of his ability. d) Discuss food options with the client so cultural needs can be met.
Discuss food options with the client so cultural needs can be met. Explanation: Discussing food options with the client is the most appropriate choice. Incorporating cultural food within the diet specifications will increase compliance with the prescribed diet. The other choices will not help to increase compliance.
A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake? a) Discourage family from visiting during meals. b) Feed the client his meal while in bed. c) Allow the client to eat when he wants to. d) Encourage the client to eat in the dining room.
Encourage the client to eat in the dining room. Explanation: Encouraging the client to eat in the dining room will allow for socialization during meal time. This will have a positive effect on the amount of food consumed and provide enjoyment
A woman consumes pasta, grains, and other carbohydrates for which purpose? a) Weight gain b) Weight loss c) Energy d) Source of fiber
Energy Explanation: The main function of carbohydrates is to provide energy.
A nurse is working with a 54-year-old with a history of constipation. The client asks if there is anything he could add to his diet to ease defecation. The nurses best response would be what? a) Alcohol b) Fiber c) Protein d) Carbohydrates
Fiber Explanation: Fiber promotes peristalsis to maintain normal bowel elimination.
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to what? a) Fluid and electrolyte levels b) Pain level during infusion c) Nausea or vomiting d) Ability to reposition
Fluid and electrolyte levels Explanation: It is important to assess fluid and electrolyte levels because total parenteral nutrition is high in nutrients and electrolytes. The other choices are not reflective of complications related to TPN.
A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if she sees a laboratory result of: a) Blood urea nitrogen (BUN) 17 mg/dL b) Hematocrit 35% c) Transferrin 360 mg/dL d) Hemoglobin 12 mg/dL
Hematocrit 35% Explanation: The hematocrit level of this client is low. Normal hematocrit is 40%-50%. The normal value for hemoglobin is 12-18 mg/dL. The normal value for transferrin is 240-480 mg/dL. The normal blood urea nitrogen is 17-18 mg/dL. (
Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube? a) Place the client in the Trendelenburg position to facilitate the fluid aspiration process. b) Continue to instill air until fluid is aspirated. c) If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. d) 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. Explanation: The nurse would measure the volume and pH of the aspirated fluid, then flush the tube with water. The nurse would not place the client in Trendelenburg position as this could lead to reflux of the feeding from the stomach and possibly cause aspiration of the solution into the lungs. The nurse would not use a small syringe or continue to instill air until fluid is aspirated.
A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client? a) Fluid Volume Deficit b) Imbalanced Nutrition, Less Than Body Requirements c) Risk for Injury d) Activity Intolerance
Imbalanced Nutrition, Less Than Body Requirements Explanation: The correct nursing diagnosis is Imbalanced Nutrition, Less Than Body Requirements as a clear liquid diet for 5 days would not provide adequate nutrition.
You are the nurse caring for a client with an enlarged thyroid gland. You anticipate which nutritional deficiency is linked to the client's condition? a) Magnesium b) Potassium c) Iodine d) Sodium
Iodine Explanation: A chronic deficiency of iodine can lead to goiter, which manifests as an enlargement of the thyroid gland.
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? a) Proteinuria b) Low serum albumin levels c) Increased white blood cells d) Low random blood glucose levels
Low serum albumin levels Explanation: Serum albumin levels are a good indicator of a client's nutritional status; decreased levels are suggestive of malnutrition. Protein in the client's urine, low blood sugars, and increased white blood cells are not necessarily indicative of malnutrition.
The nurse is caring for a client with malnutrition due to protein deficiency. Which of the following foods should be included in this client's diet? a) Roots b) Meats c) Green vegetables d) Citrus fruits
Meats Explanation: Dietary proteins come from animal and plant food sources. Milk, meat, fish, poultry, eggs, legumes (peas, beans, and peanuts), nuts, and components of grains are good sources of proteins. Animal sources contain all the essential amino acids and thus are sources of complete proteins. Green vegetables, citrus fruits, and roots and tubers are sources of vitamins and carbohydrates and will not help overcome protein deficiency.
During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her infant age 6 months. What does the nurse inform the mother? a) A new solid food should be introduced daily to the infant's diet for a week. b) Adding solid foods is fine at this age, but avoid iron-fortified foods. c) It is too early to add solid foods to the infant's diet. d) New foods should be introduced one at a time for a period of five to seven days.
New foods should be introduced one at a time for a period of five to seven days. Explanation: Solid foods are generally introduced between 4 and 6 months of age. New foods should be introduced one at a time for a period of five to seven days so that any allergic reaction can be identified. Iron-fortified foods are recommended.
A 45-year-old female client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with her morning labs and the result is 98 mg/dL. How would the nurse interpret this blood glucose? a) Normal b) Severely elevated c) Mildly elevated d) Low
Normal Explanation: Normal blood glucose is 80 to 110 mg/dL.
The nurse is providing education to a client who reports a poor calcium intake. Which of the following does the nurse tell the client is most likely to develop as a result of poor calcium intake? a) Dry eyes b) Osteoporosis c) Dental caries d) Anemia
Osteoporosis Explanation: Osteoporosis is a condition in which there is a reduction in bone density. Factors contributing to the development of osteoporosis may include chronically insufficient calcium intake, decreased estrogens, heredity factors, smoking, race, and decreased physical activity.
A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James? a) Ideal body weight (IBW) b) Overweight c) Underweight d) Obese
Overweight Explanation: A body mass index (BMI) between 25 and 29.9 is considered overweight.
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in? a) Healthy weight b) Underweight c) Obese d) Overweight
Overweight Explanation: A client with a BMI below 18.5 should be considered underweight. A client with a BMI of 18.5 to 24.9 is considered to be at a healthy weight. A client with a BMI of 25 to 29.9 is considered overweight; a client with a BMI of 30 or greater indicates obesity. A BMI greater than 40 is considered extreme obesity.
A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing? a) Vitamins b) Protein c) Carbohydrates d) Fats
Protein Explanation: Complete proteins contain sufficient amounts of the essential amino acids to maintain body tissues and to promote growth.
The nurse is providing care for a client who is ordered nothing by mouth (n.p.o.). What is an important nursing intervention? a) Provide frequent mouth care. b) Keep the water pitcher at the bedside. c) Have the client fill out a menu in advance. d) Encourage the family to eat at the bedside.
Provide frequent mouth care. Explanation: A client who is n.p.o. cannot have any food or fluids; good oral hygiene is important for comfort and to relieve a dry mouth. Keeping the water pitcher at the bedside, filling out a menu, and encouraging the family to eat at the bedside are all contraindicated for a client who is n.p.o.
The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client? a) To lose 1 pound/week, the daily intake should be decreased by 200 calories. b) Obesity is very treatable, and 50% of obese people who lose weight maintain the weight loss for 7 years. c) One pound of body fat equals approximately 5,000 calories. d) Psychological reasons for overeating should be explored, such as eating as a release for boredom.
Psychological reasons for overeating should be explored, such as eating as a release for boredom. Explanation: The nurse would need to take into consideration that psychological reasons for overeating should be explored. One pound of body fat is equal to approximately 3,500 calories. To lose 1 pound/week, the daily intake should be decreased by 500 calories per day. Obesity can be difficult to treat due to various factors.
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: a) EAR level b) UL level c) AI level d) RDA level
RDA level Explanation: The RDA level is the average dietary intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group
A nurse is caring for a client with chronic anemia. What should be included in the diet of this client? a) Dairy products b) Yellow vegetables c) Red meat d) Citrus fruits
Red meat Explanation Red meat is a source of iron. It therefore should be included in the diet of a client with chronic anemia. Dairy products, citrus fruits, and yellow vegetables are nutrient-dense foods and not sources of iron. Dairy products are sources of fat, whereas citrus fruits and yellow vegetables are sources of vitamins. (less)
The nurse is teaching a client about healthy methods to lower cholesterol. What change in the diet will aid in lowering cholesterol? a) Selecting less fresh fruit b) Switching from skim milk to whole milk c) Increasing the amount of sweets d) Reducing saturated fats
Reducing saturated fats Explanation: A client with high cholesterol would need to lower the level of saturated fats in the diet. This will have a direct impact on lowering the levels. The other choices would not lower the cholesterol levels, so they are incorrect.
A client with second-degree burns is encouraged to increase the proteins in his diet. Which food is high in protein? a) Scrambled eggs with cheese b) Pasta with alfredo sauce c) Toasted bran muffin and jelly d) Cereal and milk
Scrambled eggs with cheese Explanation: Scrambled eggs with cheese is a food choice high in protein content. The other choices are reflective of high carbohydrate content.
Which laboratory test is the best indicator of a client in need of TPN? a) Hematocrit b) Hemoglobin c) Creatinine d) Serum albumin
Serum albumin Explanation: Assessment of serum albumin level is the best indicator of a client in need of total parenteral nutrition (TPN). Clients whose levels are 2.5 g/dL or less are at severe risk for malnutrition.
A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition? a) Hemoglobin b) Oxygen saturation c) Serum albumin d) Creatinine
Serum albumin Explanation: Serum albumin levels can help measure protein levels in the body and are good indicators for nutrition status. The other choices would not reflect malnutrition status.
A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals? a) Large intestine b) Small intestine c) Liver d) Stomach
Small intestine Explanation: Most absorption of digested food and minerals occurs in the small intestines. The stomach is responsible for storing food, secreting digestive enzymes, and digestion. The large intestine forms feces and absorbs water to regulate the consistency of stool. The digestive function of the liver is the production of bile.
The nurse is caring for a patient who has dysphagia and is unable to eat independently. While assisting the patient in eating, which of the following actions is most appropriate for the nurse? a) Create a positive social environment by asking the patient about childhood food memories. b) Arrange food items in a clock face pattern and inform the patient what time on a clock corresponds to each food item. c) Speak to the patient, but reduce the number of distractions while patient is eating. d) Encourage the patient to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm.
Speak to the patient, but reduce the number of distractions while patient is eating. Explanation: Patients who have dysphagia need to eat slowly and be continually observed for signs of aspiration. Reducing the number of distractions at mealtime will help the patient achieve this. The other options do not assist a patient who is suffering from dysphagia in any way during mealtime.
The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which actions by the new nurse would require intervention by the charge nurse? a) The new nurse places the client in the left lateral recumbent position. b) The new nurse changes gloves before preparing the feeding bag. c) The new nurse asks the client if nausea or abdominal pain are present. d) The new nurse interrupts the feeding every 4 hours and aspirates gastric contents.
The new nurse places the client in the left lateral recumbent position. Explanation: This action is incorrect. The client should be assisted to a high-Fowler's position (45 degrees).
A physician orders nutritional therapy administered via a central vein for a patient who cannot take foods orally. What is the term for this type of nutrition? a) Percutaneous endoscopic gastrostomy tube (PEG) b) Percutaneous endoscopic jejunostomy tube (PEJ) c) Total parenteral nutrition (TPN) d) Partial or peripheral parenteral nutrition (PPN)
Total parenteral nutrition (TPN) Explanation: TPN is nutritional therapy that bypasses the gastrointestinal tract and is administered through a central vein. PPN is nutritional therapy used for patients who have an inadequate oral intake and require supplementation of nutrients through a peripheral vein. A PEG is a surgically placed gastrostomy tube and a PEJ is a surgically placed jejunostomy tube.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? a) Offer larger meals and encourage the client to eat as much as is comfortable. b) Reduce the frequency of meals in order to allow the client to develop an appetite. c) Offer nutritional supplements and explain the potential benefits of each. d) Try to ensure that the client's food is attractive and sufficiently warm.
Try to ensure that the client's food is attractive and sufficiently warm. Explanation: Food in the health care setting can often be unattractive and cool. Ensuring that it is appealing to the eyes and presented at the correct temperature can stimulate the client's appetite. Meals should be small and more frequent, not less frequent and larger. Supplements may be nutritionally necessary, but these do not act to increase the client's appetite.
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? a) Folic acid b) Vitamin C c) Vitamin A d) Vitamin B12
Vitamin B12 Explanation: Vitamin B12 deficiency is most commonly found in vegetarians, particularly in strict vegans. Individuals who have such rigid dietary restrictions must take care to supplement this vitamin.
A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect? a) Vitamin A b) Vitamin D c) Vitamin C d) Vitamin B
Vitamin D Explanation: Severe vitamin D deficiency manifests as rickets, osteomalacia, poor dentition, and tetany.
Which of the following is a fat-soluble vitamin? a) Vitamin E b) Vitamin B6 c) Vitamin C d) Vitamin B12
Vitamin E Explanation: Vitamin E is a fat-soluble vitamin.
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? a) Potassium b) Vitamin C c) Vitamin K d) Calcium
Vitamin K Explanation: Specific foods may interact with medications, altering the effectiveness of the drug. Vegetables high in vitamin K decrease the effectiveness of the commonly used anticoagulant warfarin. Calcium, potassium, and Vitamin C do not interact with warfarin.
A client who has bleeding tendencies has a deficiency in which vitamin? a) Vitamin A b) Vitamin K c) Vitamin C d) Vitamin B
Vitamin K Explanation: Vitamin K deficiencies are manifested in two ways: an increased tendency to hemorrhage and hemorrhagic disease of the newborn, which is common in premature or anoxic newborns.
A client who has bleeding tendencies has a deficiency in which vitamin? a) Vitamin C b) Vitamin K c) Vitamin B d) Vitamin A
Vitamin K Explanation: Vitamin K deficiencies are manifested in two ways: an increased tendency to hemorrhage and hemorrhagic disease of the newborn, which is common in premature or anoxic newborns.
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR? a) a client who is fasting b) an older adult client c) a client who is asleep d) a client who has a fever
a client who has a fever Explanation: A client who has a fever would have an increased BMR. The energy needs of the body are increased due to the client's fever. The BMR is decreased in an older adult client, a client who is fasting, and a client who is asleep.
A 28-year-old woman client is in an outpatient clinic with frequent reports of fatigue. Her physician has prescribed her ferrous sulfate 325 mg to treat iron-deficiency anemia. A nurse is teaching the client about medication administration. What food would be best consumed with her ferrous sulfate? a) a piece of bread b) a glass of milk c) a can of soda pop d) a glass of orange juice
a glass of orange juice Explanation: Concurrent administration of vitamin C and iron helps with iron absorption. Orange juice is a common and inexpensive dietary source of vitamin C.
The nurse maintains the head of the bed elevated 30 degrees for a client who is receiving continuous tube feedings in order to prevent: a) coughing. b) leakage. c) aspiration. d) residual.
aspiration. Explanation: An elevation of 30 degrees or higher will limit reflux and prevent aspiration. Residual and leakage can occur with feedings but will not cause complications such as aspiration. Coughing is not a factor.
A client has developed dysphagia secondary to a cerebrovascular accident. The nurse is aware that the client is at risk for: a) incontinence. b) gastritis. c) aspiration. d) confusion.
aspiration. Explanation: The definition of dysphagia is difficulty swallowing. This would place the client at risk for aspirating liquids. Gastritis, incontinence, and confusion can be issues but will not develop due to dysphagia.
During a general survey, the nurse documents the waist circumference of an overweight female client as 36 inches (92 cm). This client is at high risk for: a) arthritis b) Crohn's disease c) diabetes d) osteoporosis
diabetes Explanation: Women with a waist circumference greater than 35 inches are at high risk for diabetes, dyslipidemia, hypertension, and cardiovascular disease.
Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is: a) extremely obese. b) obese. c) normal weight. d) underweight.
extremely obese. Explanation: A person with a BMI below 18.5 is underweight, a BMI of 25 to 29.9 indicates an overweight individual, a BMI of 30 or greater indicates obesity, and a BMI of 40 or greater indicates extreme obesity
A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet? a) promotion of energy storage in adipose tissue b) production of hemoglobin to carry oxygen to tissues c) regulation of osmotic pressure in the blood d) maintenance of normal bowel elimination
maintenance of normal bowel elimination Explanation: Dietary fiber is a minimal source of energy but plays an essential role in stimulating peristalsis and maintaining normal bowel elimination. Proteins have specific functions of producing hemoglobin for carrying oxygen to tissues, insulin for blood glucose regulations, and albumin for regulating osmotic pressure in the blood.
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: a) anabolism. b) positive nitrogen balance. c) digestion. d) negative nitrogen balance.
negative nitrogen balance. Explanation: A negative nitrogen balance exists when excretion of nitrogen exceeds the intake.
The nurse is providing teaching for a postoperative client complaining of nausea. Which food would be the most appropriate to recommend? a) scrambled eggs b) chicken noodle soup c) saltine crackers d) chocolate donut
saltine crackers Explanation: The dry crackers are best to help control the nausea. The other foods are too heavy and may increase nausea.
A 66-year-old woman has atrial fibrillation for which she is on warfarin therapy. She asks the nurse if she has any dietary restrictions. The nurse would need to monitor the client's intake of: a) mangos. b) bananas. c) spinach. d) broccoli.
spinach. Explanation: Spinach is high in vitamin K.
A client has a nursing diagnosis of Imbalanced Nutrition, Less Than Body Requirements. The client's expected outcome is: a) to gain 5 lb in one day. b) to maintain a clear liquid diet. c) to eat dessert after every meal. d) to consume 80% of diet tray for each meal.
to consume 80% of diet tray for each meal. Explanation: Having the client consume 80% of the diet tray with each meal is a measurable and attainable goal for a client to gain weight. The other choices are not realistic goals.
The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in this situation? Select all that apply. a) Give small air boluses until gastric contents can be aspirated. b) Inspect the other nostril and attempt to pass the nasogastric tube down that nostril. c) Insert a nasointestinal tube. d) Ask the client if he needs to pause before continuing insertion. e) Have the emesis basin nearby in case client begins to vomit. f) Continue to advance tube when the client relates that he is ready.
• Ask the client if he needs to pause before continuing insertion. • Have the emesis basin nearby in case client begins to vomit. • Continue to advance tube when the client relates that he is ready. Explanation: The nurse would ask the client if she should pause before continuing insertion of the NG tube. The client retching and gagging is often part of the normal process of placing an NG tube. The nurse would continue to advance the tube when the client states he is ready. The emesis basin should be nearby in case the client begins to vomit. The nurse would not inspect the other nostril; if the client is retching and gagging, the issue is not the nostril. The nurse would not give small air boluses or insert a nasointestinal tube. (
A 6-year-old is being cared for on an inpatient unit for treatment of intestinal malabsorption syndrome. Which might be signs of calcium deficiency? Select all that apply. a) Enlarged skull b) Bowed legs c) Hypertension d) Pale mucous membranes
• Bowed legs • Enlarged skull • Hypertension Explanation: Pale mucous membranes might be a sign of anemia.
A nurse is working with a 35-year-old woman who is interested in losing weight. Based on current recommendations from the USDA and what the nurse knows about a typical U.S. diet, which are appropriate recommendations for healthy weight loss? Select all that apply. a) Increase physical activity. b) Increase the number of complex carbohydrates. c) Cut carbohydrates to 45% of intake. d) Decrease the number of calories ingested.
• Increase the number of complex carbohydrates. • Decrease the number of calories ingested. • Increase physical activity. Explanation: Cutting carbohydrates is not necessary for long-term weight loss.
A nurse is working with a 54-year-old obese man who is interested in losing weight. He asks the nurse why trans fats are so bad for you. The nurse's response includes which answers? Select all that apply. a) Trans fats raise HDL levels. b) Trans fats raise LDL levels. c) Trans fats raise cholesterol levels. d) Trans fats lower HDL levels.
• Trans fats lower HDL levels. • Trans fats raise LDL levels. • Trans fats raise cholesterol levels. Explanation: The level of HDL cholesterol, or "good" cholesterol, in the blood is lowered by trans fats.
As a nurse is aspirating the contents during a tube feeding, the nurse finds that the tube is clogged. What would be appropriate nursing interventions in this situation? Select all that apply. a) If necessary, replace the tube. b) Administer an antiemetic to the client. c) Flush with a carbonated beverage such as a cola soft drink. d) Use a stylet to unclog the tube. e) Use warm water and gentle pressure to remove clog. f) Ensure that adequate flushing is completed after each feeding
• Use warm water and gentle pressure to remove clog. • If necessary, replace the tube. • Ensure that adequate flushing is completed after each feeding. Explanation: The nurse would use warm water and gentle pressure to remove the clog. The nurse would replace the tube, if necessary. The nurse would ensure that adequate flushing is completed after each feeding.
Which measures are used by the nurse to confirm the correct placement of a nasogastric feeding tube? Select all that apply. a) measuring the pH level of aspirated contents b) measuring tube length c) monitoring carbon dioxide levels d) instilling fluid into the tube e) auscultating injected air
• measuring the pH level of aspirated contents • monitoring carbon dioxide levels • measuring tube length Explanation: Measuring pH and tube length as well as monitoring carbon dioxide are accurate ways to confirm placement. Fluid would never be instilled and auscultation of air is not considered to be reliable for tube placement.