Chapter 36: Nutrition NCLEX
A nurse is caring for an adult client who ate a chicken breast and drank a glass of water. There are 60 grams of protein in the chicken breast. Calculate the energy intake for this food. ? kilocalories
240 kilocalories To calculate total energy intake for a protein, multiply the total grams of the protein and multiply it times 4 kilocalories.
What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg? a) 24.8 b) 20.2 c) 22.4 d) 26.2
a) 24.8 A BMI of 24.8 is correct. The BMI is the ratio of height to weight that more accurately reflects total body fat stores in the general population. It is equal to: weight in kg/height in m2.
A 62-year-old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? a) Vitamin B malnutrition b) Obesity c) Dehydration d) Vitamin C deficiency
a Vitamin B malnutrition The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.
A nurse is teaching a client about diabetes and glucose monitoring. Which of the following should the nurse include in the teaching? a) Blood from the fingertips shows changes in glucose more quickly than other testing sites. b) Glucose levels will decrease with illness and stress. c) Use a forearm sample with signs and symptoms of hypoglycemia. d) Calibrate the glucose meter every six months.
a) Blood from the fingertips shows changes in glucose more quickly than other testing sites. 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.
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) Drink juice for majority of fluid intake. b) Drink nonfat or 1% milk. c) Eat a variety of enjoyable foods, but less quantity. d) Make fruits and vegetables at least half of total food intake.
a) Drink juice for majority of fluid intake.
A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first? a) Elevate the head of the bed. b) Aspirate gastric contents with a syringe. c) Flush the tube with the ordered amount of water. d) Check placement of the tube.
a) Elevate the head of the bed.
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) Low serum albumin levels b) Low random blood glucose levels c) Increased white blood cells d) Proteinuria
a) Low serum albumin levels
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) Mildly elevated c) Severely elevated d) Low
a) Normal Normal blood glucose is 80 to 110 mg/dL.
A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition? a) Peripheral parenteral nutrition b) Metabolizing nutrition c) Total parenteral nutrition d) Nasogastric feed
a) Peripheral parenteral nutrition The client requires peripheral parenteral nutrition. Peripheral parenteral nutrition provides temporary nutritional support of approximately 2000 to 2500 calories daily. It can meet a client's metabolic needs when oral intake is interrupted for 7 to 10 days, or it can be used as a supplement during a transitional period as a client begins to resume eating. Total parenteral nutrition (TPN) is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. Metabolizing nutrition is a way to replenish and supply water to the body. A nasogastric feed is administered through narrow tubing that is inserted through the client's nose into the stomach.
A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a) Remove the tray from the room. b) Administer an antiemetic and encourage the patient to take small amounts. c) Explore with the patient why she does not want to eat her food. e) Offer high-calorie snacks such as pudding and ice cream.
a) Remove the tray from the room. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.
A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process? a) Stroke the underside of the patient's chin to promote swallowing. b) Serve meals in different places and at different times. c) Offer a whole tray of various foods to choose from. d) Avoid between-meal snacks to ensure hunger at mealtime.
a) Stroke the underside of the patient's chin to promote swallowing. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.
A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? a) The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. b) The nurse wets a washcloth and washes the area around the tube with soap and water. c) The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. d) The nurse tapes a gauze dressing over the site after cleansing it.
a) The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.
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) Total parenteral nutrition (TPN) b) Percutaneous endoscopic gastrostomy tube (PEG) c) Percutaneous endoscopic jejunostomy tube (PEJ) d) Partial or peripheral parenteral nutrition (PPN)
a) Total parenteral nutrition (TPN) 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.
A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment? a) Use warm water and gentle pressure to remove the clog. b) Use a stylet to unclog the tubes. c) Administer cola to remove the clog. d) Replace the tube with a new one.
a) Use warm water and gentle pressure to remove the clog. In order to remove a clog in a feeding tube, the nurse should try using warm water and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.
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) Vitamin B12 b) Vitamin C c) Folic acid d) Vitamin A
a) Vitamin B12 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.
Which nutrient is most vital to life? a) Water b) Vitamins c) Carbohydrates d) Minerals
a) Water Water is more vital to life than food because it provides the fluid medium necessary for all chemical reactions, it participates in many reactions, and it is not stored in the body. Water dissolves many solutes and aids digestion, absorption, circulation, and excretion.
A woman age 20 years has announced her intention to implement a zero-fat diet in order to lose weight and maximize her health. What is a potential consequence of completely eliminating fat sources from the woman's diet? a) impaired vitamin absorption b) decreased water absorption in the colon c) impaired tissue growth and repair d) decreased production of antibodies
a) impaired vitamin absorption In addition to providing caloric needs, fats are necessary for the absorption of fat-soluble vitamins. It would be inadvisable to wholly eliminate fats from the diet in an effort to limit calorie intake. Fat does not directly contribute to tissue growth, water absorption in the bowel, or antibody production.
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) maintenance of normal bowel elimination b) promotion of energy storage in adipose tissue c) production of hemoglobin to carry oxygen to tissues d) regulation of osmotic pressure in the blood
a) maintenance of normal bowel elimination 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. Fats perform the important functions of energy storage of adipose tissue, vitamin absorption, and transport of fat-soluble vitamins A, D, E, and K.
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) spinach. b) mangos. c) bananas. d) broccoli.
a) spinach.
A nurse is evaluating patients to determine their need for total parenteral nutrition (TPN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a) A patient with irritable bowel syndrome who has intractable diarrhea b) A patient with celiac disease not absorbing nutrients from the GI tract c) A patient who is underweight and needs short-term nutritional support d) A patient who is comatose and needs long-term nutritional support e) A patient who has anorexia and refuses to take foods via the oral route f) A patient with burns who has not been able to eat adequately for 5 days
a, b, f Assessment criteria used to determine the need for TPN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract (patient with celiac disease) and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (Worthington & Gilbert, 2012; A.S.P.E.N., 2002). TPN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.
A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and show signs of respiratory distress. What would be the priority action of the nurse upon this assessment? a) Keep the tube in place and notify the primary care provider immediately. b) Stop advancing the tube and pull it back into the nasal area. c) Ask the patient if he wants the nurse to stop the procedure. d) Call for help to perform CPR.
b) Stop advancing the tube and pull it back into the nasal area. As the tube is passing through the pharynx and the patient begins to cough and show respiratory distress, the nurse should stop advancing the tube and pull it back into the nasal area. The nurse should also support the patient as he regains normal breathing ability and composure and have him try again if he feels able to.
The nurse researches factors that may alter nutrition. Which statements accurately describe factors that influence nutritional status? Select all that apply. a) Nutritional needs per unit of body weight are greater in infancy than at any other time in life. b) Because of the changes related to aging, the caloric needs of the older adult increase. c) During adulthood, there is an increase in the basal metabolic rate (BMR) with each decade. d) During pregnancy and lactation, nutrient requirements increase. e) Men and women differ in their nutrient requirements. f) Trauma, surgery, and burns decrease nutrient requirements.
a, d, e The nurse found that during pregnancy and lactation, nutrient requirements increase. The nurse would also note that nutritional needs per unit of body weight are greater in infancy than at any other time in life. The nurse would find that men and women differ in their nutrient requirements. Trauma, surgery, and burns increase nutrient requirements. The BMR decreases with each decade in adulthood. The caloric needs of the older adult decrease, not increase.
A nurse is teaching a client about nutrition. Which facts should the nurse include about fat-soluble vitamins? Select all that apply. a) Fat-soluble vitamins are A, D, E, and K. b) Deficiencies of fat-soluble vitamins can occur with malabsorption syndromes. c) The body excretes all excess water-soluble vitamins. d) Fat-soluble vitamins must be attached to a protein for transport in the blood. e) Deficiencies may take hours or days to develop.
a, d, e Fat-soluble vitamins are A, D, E, and K. These vitamins must be attached to a protein to be transported through the blood. Deficiencies can occur during malabsorption diseases because fat digestion or absorption is altered. Fat-soluble vitamins are stored in the liver and adipose tissue. Therefore, deficiencies can take weeks, months, or years to develop.
The nurse identifies the correct steps for removal of a nasogastric tube. Place the steps in sequential order. a) Identify the client b) Discontinue suction c) Put on nonsterile gloves d) Raise the bed to 30-45° e) Remove tube while client holds breath
a-d-c-b-e Identify the client Raise the bed to 30-45° Put on nonsterile gloves Discontinue suction Remove tube while client holds breath
A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to delete per day in order to accomplish this goal? a) 250 calories b) 500 calories c) 750 calories d) 1000 calories
b) 500 calories 1 lb (0.45 kg) of body fat equals about 3,500 cal. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increased or decreased, respectively, by 500 cal (3,500 cal divided by 7 days = 500 cal/day). Similarly, a weight gain or loss of 2 lb (0.9 kg) per week would require an adjustment of 1,000 cal/day.
A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 pounds. What would the nurse document as his BMI? a) 50.5 b) 52.4 c) 54.5 d) 55.2
b) 52.4
A nurse documents a client's hemoglobin as 8 g/dL. What nutritional condition does this biochemical data signify? a) Malnutrition b) Anemia c) Dehydration d) Malabsorption
b) Anemia 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 caring for an older adult client who is admitted with failure to thrive to a medical surgical unit. Which laboratory value would the nurse expect to find with this diagnosis? a) Prealbumin 43 mg/dL b) Blood urea nitrogen 15 mg/dL c) Creatinine 1.5 mg/dL d) Serum albumin 4.8 g/dL
b) Blood urea nitrogen 15 mg/dL Failure to thrive includes weight loss and malnutrition. The blood urea nitrogen (BUN) level is low at 15 mg/dL. This decrease can indicate malnutrition. Normal BUN is 17-18 mg/dL. The serum albumin, prealbumin, and creatinine levels are within normal limits.
Which nursing action associated with successful tube feedings follows recommended guidelines? a) Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. b) Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. c) Prevent contamination during enteral feedings by using an open system. d) Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid.
b) Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. 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) Adolescents eat their food slowly. b) Childhood nutrition problems may worsen during adolescence. c) Nutritional needs decrease during adolescence. d) Adolescents tend to eat meals at home.
b) Childhood nutrition problems may worsen during adolescence.
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? a) Carbonated beverages b) Clear fruit juices c) Mashed potatoes d) Boiled vegetables
b) Clear fruit juices Once nausea is relieved, assisting the client in resuming fluid intake and nourishment becomes a priority. The nurse starts this process gradually, offering sips of clear fluids, such as fruit juices first. Bland foods, such as boiled vegetables or mashed potatoes, can be given when the client's nausea is completely relieved and the client is able to hold fluids down. Carbonated beverages may not be appropriate for the client in this case because it may contribute to feelings of abdominal bloating that can aggravate nausea.
A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake? a) Allow the client to eat when he wants to. b) Encourage the client to eat in the dining room. c) Feed the client his meal while in bed. d) Discourage family from visiting during meals.
b) Encourage the client to eat in the dining room.
A 56-year-old male patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating his appetite? a) Administering pain medication after meals. b) Encouraging food from home when possible. c) Scheduling his respiratory therapy before each meal. d) Reinforcing the importance of his eating exactly what is delivered to him.
b) Encouraging food from home when possible. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.
Which factor does not increase the basal metabolic rate? a) Stress b) Exercise c) Growth d) Fever
b) Exercise
Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube? a) Continue to instill air until fluid is aspirated. b) If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. c) Place the client in the Trendelenburg position to facilitate the fluid aspiration process. d) Use a small syringe and insert 10 mL of air.
b) If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. 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.
Which food eaten with peanut butter would provide the client with complete protein? a) Wheat bread b) Milk c) Tofu (soybean curd) d) Carrots
b) Milk Complete proteins, such as milk, typically come from animal sources. Proteins from plant sources, such as soybeans, are usually incomplete. Carrots and bread are not significant protein sources.
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) Anemia b) Osteoporosis c) Dental caries d) Dry eyes
b) Osteoporosis
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) Obesity is very treatable, and 50% of obese people who lose weight maintain the weight loss for 7 years. b) Psychological reasons for overeating should be explored, such as eating as a release for boredom. c) One pound of body fat equals approximately 5,000 calories. d) To lose 1 pound/week, the daily intake should be decreased by 200 calories.
b) Psychological reasons for overeating should be explored, such as eating as a release for boredom.
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) UL level b) RDA level c) AI level d) EAR level
b) RDA level
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) 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. b) Speak to the patient, but reduce the number of distractions while patient is eating. c) Create a positive social environment by asking the patient about childhood food memories. d) Arrange food items in a clock face pattern and inform the patient what time on a clock corresponds to each food item.
b) Speak to the patient, but reduce the number of distractions while patient is eating. 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 asks the client if nausea or abdominal pain are present. b) The new nurse places the client in the left lateral recumbent position. c) The new nurse changes gloves before preparing the feeding bag. d) The new nurse interrupts the feeding every 4 hours and aspirates gastric contents.
b) The new nurse places the client in the left lateral recumbent position.
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) Reduce the frequency of meals in order to allow the client to develop an appetite. b) Try to ensure that the client's food is attractive and sufficiently warm. c) Offer nutritional supplements and explain the potential benefits of each. d) Offer larger meals and encourage the client to eat as much as is comfortable.
b) Try to ensure that the client's food is attractive and sufficiently warm. 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.
Which vitamin is found only in animal foods? a) Vitamin C b) Vitamin B12 c) Vitamin D d) Vitamin A
b) Vitamin B12 Vitamin B12 functions in the formation of mature red blood cells and in synthesis of DNA and RNA. This vitamin is only found in animal foods (meats, fish, poultry, milk, and eggs).
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR? a) an older adult client b) a client who has a fever c) a client who is asleep d) a client who is fasting
b) a client who has a fever 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 glass of milk b) a glass of orange juice c) a piece of bread d) a can of soda pop
b) a glass of orange juice Concurrent administration of vitamin C and iron helps with iron absorption. Orange juice is a common and inexpensive dietary source of vitamin C.
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) osteoporosis b) diabetes c) arthritis d) Crohn's disease
b) diabetes Women with a waist circumference greater than 35 inches are at high risk for diabetes, dyslipidemia, hypertension, and cardiovascular disease.
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) Administer an antiemetic to the client. b) If necessary, replace the tube. c) Use warm water and gentle pressure to remove clog. d) Flush with a carbonated beverage such as a cola soft drink. e) Use a stylet to unclog the tube. f) Ensure that adequate flushing is completed after each feeding.
b, c, f 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. It is not evidence based practice to flush the feeding tube with a carbonated beverage. The nurse would not use a stylet to unclog the tube. This could cause damage to the feeding tube. The nurse would not administer an antiemetic to the client because the tube is clogged. This would not help the situation.
A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply. a) Non-smokers b) Adolescents c) Middle-age adults d) Strict vegetarians e) Pregnant or lactating women
b, d, e
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) Inspect the other nostril and attempt to pass the nasogastric tube down that nostril. b) Ask the client if he needs to pause before continuing insertion. c) Insert a nasointestinal tube. d) Continue to advance tube when the client relates that he is ready. e) Have the emesis basin nearby in case client begins to vomit. f) Give small air boluses until gastric contents can be aspirated.
b, d, e 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 nurse is caring for a client receiving total parenteral nutrition (TPN). Which facts should the nurse understand about TPN therapy? Select all that apply. a) Lipids are added to decrease caloric value. b) TPN has three primary components: proteins, carbohydrates, and fats. c) TPN is an isotonic solution. d) TPN requires a PICC line or central venous access. e) TPN has a high glucose concentration.
b, d, e Total parenteral nutrition (TPN) has three primary components: proteins, carbohydrates, and fats; it also has a high glucose concentration. TPN does require a PICC line or central venous access. TPN is a hypertonic solution. Lipids or fats are added to add caloric value to meet energy requirements.
A woman is 6 weeks pregnant and is in a clinic for her first prenatal exam. She asks a nurse how her nutritional needs have changed now that she is pregnant. Which is the nurse's best response? a) "You are now eating for two. Enjoy!" b) "You should double your caloric intake to sustain the pregnancy." c) "You will need additional nutrients such as calcium, folic acid, and protein." d) "Food choices during pregnancy have little impact on your baby."
c) "You will need additional nutrients such as calcium, folic acid, and protein." Extra calcium, iron, and folic acid are often obtained via prenatal vitamins. Pregnant woman only need about 200 extra calories per day to sustain a pregnancy.
A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? a) A 19-year-old patient who is a vegan b) An elderly patient who takes daily nutritional drinks c) A 43-year-old patient who takes ginko bilboa and an aspirin daily d) An infant who is breast-feeding
c) A 43-year-old patient who takes ginko bilboa and an aspirin daily A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breast-feeding do not adversely affect the outcomes of surgery.
At what period of life do nutrient needs stabilize? a) Adolescence b) Infancy c) Adulthood d) Pregnancy
c) Adulthood 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.
The nurse is concerned that a client of Asian descent is not eating the meals provided on the diet tray. What would be the most effective measure to help increase food consumption? a) Change to diet to full fluids. b) Tell the client it is important that he eats. c) Ask the client what cultural foods he enjoys. d) Discourage the family from bringing in food.
c) Ask the client what cultural foods he enjoys.
A nurse is caring for a client who has a decrease in appetite. Which of the following actions by the nurse would be appropriate? a) Give medications with the meal tray. b) Ask for double portions for the client. c) Assist with oral hygiene before serving the meal tray. d) Move the bedside commode to the other side of the bed away from the meal tray.
c) Assist with oral hygiene before serving the meal tray. The client should be assisted with oral hygiene before serving the meal tray. This helps with the taste of the food. Serve small, frequent meals to avoid overwhelming the client. The bedside commode should be emptied of urine and feces before meal time. If possible, place the bedside commode in the bathroom. Medications and procedures should be scheduled when they will not interfere with meal time.
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to what? a) Pain level during infusion b) Nausea or vomiting c) Fluid and electrolyte levels d) Ability to reposition
c) Fluid and electrolyte levels 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 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? a) Folate b) B complex c) Niacin d) Riboflavin
c) Niacin One of the side effects of niacin ingestion can be flushing and itching. B complex, folate, and riboflavin have no known side effects.
A nurse is educating a group of adolescent girls on bone and teeth growth. Which fat-soluble vitamin assists to build bone and teeth? a) Vitamin E b) Vitamin K c) Vitamin D d) Vitamin A
c) Vitamin D
What health problem may occur in a person who is on a low-carbohydrate diet for a long period of time? a) obesity b) infection c) ketosis d) fatigue
c) ketosis
A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? a) Auscultate the bowel sounds. b) Measure the gastric aspirate pH. c) Measure the amount of residual in the tube. d) Order radiographic examination of the tube.
d) Order radiographic examination of the tube.
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. a) Listen for gurgling at the end of the nasogastric tube. b) Auscultate injected air over the epigastric space. c) Do a radiographic examination. d) Aspirate stomach contents to check pH level. e) Measure tube length and tube marking.
c, d, e The correct methods to check placement of the nasogastric tube include aspiration of stomach contents to check pH level, measurement of tube length and tube marking, and radiographic examination. Auscultation of injected air over the epigastric space is no longer an accepted or reliable way to check placement of the nasogastric tube. Listening for gurgling at the end of the nasogastric tube is not a way to ensure correct placement.
A nurse has received a physician's order to insert a nasogastric tube in an adult client. What is the correct order for insertion of a nasogastric tube? a) Insert the nasogastric tube to the pharynx. b) Have the client take small sips of water. c) Measure the insertion distance. d) Have the client tuck his chin to the chest. e) Aspirate a small amount of stomach contents and check pH. f) Insert the tube to the indicated mark.
c-a-d-b-f-e The nurse should follow this order for the insertion of a nasogastric tube: Measure the insertion distance. Insert the nasogastric tube to the pharynx. Have the client tuck his chin to the chest. Have the client take small sips of water. Insert the tube to the indicated mark. Aspirate a small amount of stomach contents and check pH.
A nurse is conducting a health history interview for an older adult. Which question or statement should the nurse prioritize for nutritional assessment? a) "Why don't you consider eating more meat? You need protein." b) "When did you first notice that you had this sore on your heel?" c) "What kinds of foods did you prepare when you were younger?" d) "Which prescribed and over-the-counter medicines do you take?"
d) "Which prescribed and over-the-counter medicines do you take?" When collecting dietary data for an older adult, it is important to gather information about prescribed and over-the-counter medications to assess for food-drug interactions and adverse effects of medications.
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? a) 130 lb/ 58.9 kg b) 135 lb/ 61.2 kg c) 140 lb/ 63.5 kg d) 145 lb/ 65.7 kg
d) 145 lb/ 65.7 kg A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet.
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) Clear broth, hot tea, and yogurt c) Fat-free broth, ginger ale, and custard d) Bouillon, apple juice, and gelatin
d) Bouillon, apple juice, and gelatin 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.
Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is which of the following? a) Underweight b) Obese c) Normal weight d) Extremely obese
d) Extremely obese
Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index (BMI) of 18? a) Risk for Imbalanced Nutrition: More Than Body Requirements b) Imbalanced Nutrition: More Than Body Requirements c) Readiness for Enhanced Nutrition d) Imbalanced Nutrition: Less Than Body Requirements
d) Imbalanced Nutrition: Less Than Body Requirements
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) Sodium d) Iodine
d) Iodine
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) Obese b) Underweight c) Healthy weight d) Overweight
d) Overweight 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 nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a) Feed the patient solids first and then liquids last. b) Place the head of the bed at a 30-degree angle during feeding. c) Puree all foods to a liquid consistency. d) Provide a thirty-minute rest period prior to mealtime.
d) Provide a thirty-minute rest period prior to mealtime. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.
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) Increasing the amount of sweets c) Switching from skim milk to whole milk d) Reducing saturated fats
d) Reducing saturated fats
A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition? a) Oxygen saturation b) Hemoglobin c) Creatinine d) Serum albumin
d) Serum albumin 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 assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a) The patient consumed 75% of the liquids on her breakfast tray. b) The patient tells you she is hungry. c) The patient's abdomen is soft, nondistended, with bowel sounds. d) The patient reports fullness and diarrhea after breakfast.
d) The patient reports fullness and diarrhea after breakfast. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.
The nurse is providing care for a patient whose abdominal fistula has necessitated the use of total parenteral nutrition (TPN). What action should the nurse implement in the care of this patient? a) Flush the patient's central line with 30 to 60 mL of sterile water every 4 hours. b) Add medications to the TPN solutions only after dissolving them in sterile water. c) Change the bag of TPN solution at least every 72 hours. d) Use a pump to administer the patient's TPN.
d) Use a pump to administer the patient's TPN. TPN must always be administered with a pump. Central lines that are in use do not require flushing, and central lines in all circumstances are not normally flushed with sterile water. Medications may only be added by pharmacy prior to administration of the solution. TPN bags are changed a minimum of every 24 hours.
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) digestion. b) anabolism. c) positive nitrogen balance. d) negative nitrogen balance.
d) negative nitrogen balance.
What best defines ideal body weight (IBW)? a) the weight at which one feels most attractive b) weighing 10 pounds less than recommended c) a weight that is predetermined for all people d) optimal weight for optimal health
d) optimal weight for optimal health
