Foundations U2 W6 Nutrition (ATI Questions)

a nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamins." Which of the following responses should the nurse make? - if taken four or more days a week, a multivitamin provides all the nutrients you need - as long as you take a multivitamin daily, you do not need to eat a varied diet each day - a multivitamin should not be used in place of a nutritious diet - as long as the multivitamin isn't generic, it can replace unhealthy dietary choices

- a multivitamin should not be used in place of a nutritious diet The nurse should tell the client that supplemental vitamins should not be used as a substitute for a nutritious diet. The client should eat a varied, nutritious diet daily even while taking a multivitamin.

a nurse is caring for a client who states, "I only eat a diet high in protein and carbohydrates." which of the following responses should the nurse make? - make sure to get enough servings of red meat in your diet daily - your diet is varied but should also be high in calorie intake - a varied diet should be high in protein and carbohydrate consumption - a nutritious diet should include carbohydrates, protein, fiber, and healthy fats

- a nutritious diet should include carbohydrates, protein, fiber, and healthy fats The nurse should instruct the client to consume a balanced diet from a variety of different food groups, such as dairy, grains, fruits, vegetables, and proteins.

a nurse is preparing to assist with feeding a client who is at risk for aspiration. which of the following actions should the nurse take? - position the client upright at a 45-degree angle - turn on the television per the client's request - avoid allowing the client to drink until the meal is finished - cut the client's food into small bites

- cut the client's food into small bites To prevent aspiration, the nurse should cut food into small bites. The client should be positioned at a 90° angle to prevent complications during feeding. While feeding a client who is at risk for aspiration, distractions should be avoided. The nurse should not turn on the television during feeding because it can distract the client, which could result in aspiration. The nurse should provide the client sips of their drink in between bites after they have completely swallowed their food.

a nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make? - a lack of protein can cause a problem with cavities - cavities can be caused by a diet low in vitamin C - increasing your consumption of leafy green vegetables and tomatoes can help with this - drinking sugary beverages can make you prone to cavities

- drinking sugary beverages can make you prone to cavities

a nurse is caring for client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (select all that apply) - increasing daily fiber intake can help alleviate the issue of constipation - eating more whole grains can promote regular bowel movements - consume 10g of fiber per day - foods such as white rice increase fiber intake - decreasing daily fiber intake can help alleviate digestive discomfort

- increasing daily fiber intake can help alleviate the issue of constipation - eating more whole grains can promote regular bowl movements **An adequate amount of daily fiber intake helps relieve constipation by promoting bowel movements. Whole grains contain fiber, which helps to regulate bowel movements. **The nurse should identify that the daily fiber recommendation is 25 g per day for women and 38 g per day for men. Therefore, 10 g of fiber per day is an inadequate amount of daily dietary fiber. Brown rice is a whole grain that increases fiber intake. The nurse should instruct the client to consume brown rice because it is a whole grain that increases fiber intake, which will decrease constipation. Decreasing daily fiber intake can lead to digestive discomfort if a client isn't getting enough daily fiber to begin with.

a nurse is caring for a client who is receiving tube feedings via PEG. which of the following actions should the nurse implement in order to help prevent the client from aspirating? - keep the client's head elevated to at least 30 degrees for a minimum of one hour after a feeding - verify the initial tube placement with an x-ray after the first feeding - check the client's tube feeding tolerance every 12 hours - check the pH of the gastric contents each day

- keep the client's head elevated to at least 30 degrees for a minimum of one hour after a feeding The nurse should keep the client's head elevated to at least 30° for a minimum of 1 hr after the feeding because this gives the client time to digest the feeding and helps prevent aspiration. The nurse should verify the initial tube placement with an x-ray prior to using the tube for feeding. The nurse should check the client's tube feeding tolerance every 4 hr. The nurse should check the pH of the gastric contents every 4 hr to verify tube placement. This helps reduce the risk for aspiration due to tube movement or dislodgement.

a nurse is discussing macronutrients with a client. Which of the following statements should the nurse make? - macronutrients include vitamins and minerals, which your body needs in a large amount - macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet - macronutrients include carbohydrates and fats, which your body needs very little of - while essential, macronutrients should be limited to weekly consumption

- macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet Macronutrients are essential parts of a diet and include proteins, fats, and carbohydrates. These provide the body with energy to function and are the building blocks of the diet. A. Micronutrients include the vitamins and minerals that are needed in small amounts. C. Micronutrients include the vitamins and minerals that are needed in small amounts. D. Macronutrients are essential to a client's diet and should be eaten daily.

a nurse is preparing to measure a nasogastric tube for insertion. the nurse recalls that the client's xyphoid process should be used at the last place of measurement. which of the following landmarks should the nurse measure before the xyphoid process? - measure the bottom of the ear - measure from the tip of the chin - measure from the bottom of the jaw line - measure from the tip of the nose to the earlobe

- measure from the tip of the nose to the earlobe The NG tube is measured from the tip of the nose to the earlobe, then from the earlobe to the xyphoid process. This would give an accurate measurement for tube insertion, allowing appropriate tube placement.

a nurse is assessing a client who is experiencing digestive issues. which of the following findings should the nurse expect to find? (select all that apply) - nausea abdominal pain diarrhea - reports of bloating -reports of excessive salivation

- nausea abdominal pain diarrhea - reports of bloating The nurse should identify that excessive salivation is not an expected finding for a client who is experiencing digestive issues.

a nurse is caring for a client who has renal disease and must limit potassium intake. which of the following foods should the nurse instruct the client to avoid because they are high in potassium? - potatoes - bananas - dried beans - spinach - tomatoes - apples

- potatoes - bananas - dried beans - spinach - tomatoes Consuming foods that are high in potassium can lead to heart dysrythmias and increase the risk of myocardial infarction for clients who have renal disease. Apples are not high in potassium. Choose low-potassium foods such as pasta, noodles, rice, tortillas, and bagels. And avoid high-potassium foods, including things like milk, bananas, oranges, spinach, tomatoes, and broccoli.

a nurse is caring for a non-diabetic client who has a new prescription for a fasting blood glucose check. the nurse checks the client's blood glucose and it is at 67 mg/dL. which of the following actions should the nurse take next? - document the client's blood glucose level - report the client's blood glucose level to the provider - provide the client with a 15-g carbohydrate snack - recheck the blood sugar in 15 minutes

- provide the client with a 15-g carbohydrate snack According to evidence-based practice, the nurse should first provide the client with a 15-g carbohydrate snack to help bring up their blood glucose level to the expected reference range. The client's glucose level is low, less than 70 mg/dL, which means the client is hypoglycemic. The other choices come after.

a nurse is assessing a client's hair and notes that is is brittle. which of the following should the nurse determine about a client's nutritional intake? - the client is not getting enough vitamin A - the client has insufficient protein in their diet - the client needs more vitamin D from sun exposure - the client needs to eat five servings of fruits and vegetables daily

- the client has insufficient protein in their diet Protein helps promote healthy hair and prevents brittle hair and hair loss. Therefore, the nurse should identify that this client might have inadequate protein intake.

a nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. the nurse receives a new NPO diet prescription for the client. which of the following should the nurse identify as the rationale for the provider's prescription? - the client is at risk for aspiration due to the upcoming surgery - the client is at risk for dysphagia due to the upcoming surgery - the nutrients consumed as a part of the regular diet will interact with the sedation used in the procedure - the client reports having to drink a few sips of water before the procedure

- the client is at risk for aspiration due to the upcoming surgery The client is at risk for aspiration due to their upcoming surgery with sedation. To decrease the risk of aspiration, the client should remain NPO prior to the surgery. Dysphagia is difficulty swallowing, usually due to a stroke or other issue. There is not a risk of interaction between the nutrient intake and the medication used for sedation. The NPO prescription is intended to decrease the risk of aspiration of food due to sedation. The nurse should identify that the client should not drink any water prior to the procedure because the provider has prescribed an NPO diet. However, this is not the rationale for the provider's NPO prescription.

a nurse is caring for a client who is prescribed a low glycemic index diet. the client states, "I don't understand what this means." which of the following responses should the nurse make? (select all that apply) - the glycemic index of a food relates to its ability to increase the blood glucose level - you should eat foods such as whole grains, fruits, and vegetables - consuming white bread will increase your blood glucose level slowly - try to limit or avoid potatoes due to their high glycemic index - foods with a high glycemic index will cause your blood glucose to increase rapidly

- the glycemic index of a food relates to its ability to increase the blood glucose level - you should eat foods such as whole grains, fruits, and vegetables - try to limit or avoid potatoes due to their high glycemic index - foods with a high glycemic index will cause your blood glucose to increase rapidly **White bread has a high glycemic index. Therefore, consuming white bread causes a rapid increase in blood glucose level.

a nurse is caring for a client who has a new prescription for parenteral nutrition. the client states "I am scared that I will be on this therapy the rest of my life." which of the following responses should the nurse make? - there is a good chance you will have to be on this therapy for the rest of your life - parenteral nutrition is very common and should not interfere with your daily activities - this type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change - I am sure you will need parenteral nutrition temporarily

- this type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change This response gives the client objective information without false reassurance.

a nurse is caring for a client who has a high phosphorus level. which of the following instructions regarding food should the nurse provide? - you should eat white bread - you can drink 2 cups of milk per day - you should limit broccoli to 3 cups per week - you can have four servings of oatmeal per week

- you should eat white bread The nurse should instruct the client to eat white bread instead whole-grain bread. Whole grains are high in phosphorus. The nurse should instruct the client to limit milk intake to 1 cup per day because of the level of phosphorus. The nurse should instruct the client to limit broccoli intake to 1 cup per week because of the level of phosphorus. The nurse should instruct the client to limit oatmeal, granola, bran, and wheat cereals to one serving per week because of the level of phosphorus.

a nurse is caring for a client whose provider prescribed a heart-healthy diet. which of the following information should the nurse include for the client regarding heart-healthy diets? (select all that apply) - you should limit saturated fats in your diet - you should increase sodium intake in your taste - eat foods with whole grains in your diet - it's important to eat larger portions of fruits and vegetables - limiting high-calorie food intake will promote adherence to your new diet - continue to avoid skim milk and lean meats

- you should limit saturated fats in your diet - eat foods with whole grains in your diet - it's important to eat larger portions of fruits and vegetables - limiting high-calorie food intake will promote adherence to your new diet

a nurse is caring for a client who has a new prescription for a clear liquid diet. the client asks the nurse, "how long will I have to be on this type of diet?" Which of the following responses should the nurse make? - you will be on this diet as long as the provider feels you need to be - you might be on this diet for a week or two - you should not be on this diet for more than a few days - you should speak with the provider about your concern

- you should not be on this diet for more than a few days The nurse should identify that a clear liquid diet should be limited to a few days because this type of diet has inadequate nutritional value. A. This is nontherapeutic communication from the nurse and does not give the client any information about the client's concerns. B. This diet will not offer enough nutritional support for that time frame. The nurse should instruct the client that this diet is typically restricted to a few days because of the limited calories and nutrients it offers. D. While the provider will make the decision to change the client's diet, this response avoids the question completely without giving any factual information. This is a nontherapeutic response by the nurse.

A nurse should recognize that which of the following is correct regarding albumin level as a diagnostic marker for nutritional status? A) Albumin level is a poor short-term indicator of protein status B) Hydration status does not affect a patient's albumin level C) An albumin level of 3.2 g/dL is within the normal reference range D) Albumin level is calculated by keeping a 24-hr record of protein intake

A) Albumin level is a poor short-term indicator of protein status Albumin is not sensitive to acute changes in nutritional status. Its long half-life of 21 days makes it a better indicator of chronic illness states than of current protein status at a given point in time. B. Hydration status does affect albumin level, as do other factors such as hemorrhage, wound drainage, age, stress, and surgery. C. Expected albumin levels range from 3.5 to 5.4 g/dL. A level of 3.2 g/dL reflects mild protein malnutrition. D. Albumin level is determined by a blood test.

To assess a stroke patient for complications secondary to inadequate swallowing, the nurse should do which of the following? A) Auscultate the patient's lungs B) Place the tip of a tongue depressor on the patient's posterior tongue C) With a penlight, inspect the patient's uvula and the soft palate D) Place fingers on the patient's throat at the level of the larynx and ask him to swallow

A) Auscultate the patient's lungs Silent aspirations are a common complication of swallowing impairment. B. Placement of a tongue depressor on the posterior tongue is likely to elicit the gag reflex. Testing the gag reflex helps confirm the function of cranial nerve IX, the glossopharyngeal nerve, but it does not demonstrate the act of swallowing. C. Examining these structures would not give the nurse any helpful information about the client's ability to swallow without difficulty. D. The nurse should be able to palpate the movement of the pharynx.

Which of the following are appropriate choices for a patient described a full liquid diet? A) Plain yogurt B) Custard C) Pureed vegetables D) Mashed potatoes E) Pureed meat F) Gelatin G) Ice cream

A) Plain yogurt B) Custard F) Gelatin G) Ice cream A full liquid diet includes smooth-textured dairy products, such as yogurt (with no added fruit or solids), and all the elements of a clear liquid diet, such as carbonated beverages. Mashed potatoes, pureed meat, and pureed vegetables are not permitted until the client progresses to a pureed diet or beyond.

When checking for nasogastric tube placement, he nurse should conduct which of the following procedures? A) Instill 20 mL of air into the tube and listen for a whooshing sound B) Aspirate stomach contents and check the pH C) Aspirate stomach contents and check the color D) Auscultate lung sounds

B) Aspirate stomach contents and check the pH Checking the pH of stomach contents is the recommended method for checking tube placement. The pH measurement of gastric aspirate is 4 or less. A pH measurement of gastric aspirate can be used to monitor placement after the initial placement has been verified. Although this method has been used in the past, evidence-based research indicates that injecting air into the tube and listening over the client's abdomen is not a reliable method to verify tube placement. This method does not indicate the tube is in place. Gastric contents are typically cloudy and green. Identifying the color of gastric contents is not used to verify initial placement of a nasogastric tube. If an aspiration is suspected, the nurse should auscultate the client's lungs. However, auscultating lung sounds does not verify the placement of a nasogastric tube.

Which of the following formulas is appropriate to administer to a patient who has a dysfunctional gastrointestinal tract? A) Modular B) Elemental C) Polymeric D) Specialty

B) Elemental Elemental (elemental formulas contain predigested nutrients that are easy for a partially functional gastrointestinal tract to absorb.) A. Modular formulas are single-nutrient formulas and require a functioning gastrointestinal tract that can absorb whole nutrients. C. Polymeric formulas are whole-nutrient formulas and require a functioning gastrointestinal tract that can absorb whole nutrients. D. Specialty formulas meet specific nutritional needs for clients who have a conditions such as HIV, liver failure, or clients who have pulmonary disease.

A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient? A) Nasogastric tube B) Nasointestinal Tube C) Percutaneous endoscopic gastronomy tube D) Percutaneous endoscopic jejunostomy tube

B) Nasointestinal Tube (A lack of motility in the stomach (gastric ileus) would prevent the digestion of enteral formula placed in the stomach.)

A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. which of the following actions should the nurse take to prevent dry mucous membranes? A) Allow the patient to suck on ice chips B) Provide frequent mouth care C) Apply the petroleum jelly to the patient's naris D Offer throat lozenges for the patient to sue

B) Provide frequent mouth care The nurse should perform frequent mouth care, such as brushing their teeth and providing oral swabs, to keep the client's mucous membranes from becoming dry and irritated. Ice chips are contraindicated for a client who is NPO. Petroleum jelly should not be used due to the risk for aspiration of the oily compound. The client should use a water-based lubricant. Throat lozenges are contraindicated for a client who is NPO.

A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of the following? A) Chest xray B) Swallowing examination C) Nasogastric tube insertion D) Olfactory nerve evaluation

B) Swallowing examination Clients at high risk for aspiration include those with a decreased level of consciousness. This client has some periods of decreased alertness, thus a swallowing examination is essential to determine their ability to ingest food safely by mouth. A. Unless the client has had any trauma in the chest area, this is not mandatory and is unlikely to provide any data confirming or refuting their ability to ingest food safely by mouth. C. Unless it has been determined that this client cannot ingest food safely by mouth, this intervention is unlikely to be prescribed. D. Testing cranial nerve I, the olfactory nerve, determines the acuity of the client's sense of smell. Although this sense can be associated with the client's enjoyment of food, testing of this sense would not provide any data confirming or refuting their ability to ingest food safely by mouth.

A nurse is providing teaching about risk for aspiration w/ a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? A. A feeling of fullness B. Persistent coughing C. Discomfort in the naris D. Post-feeding belching

B. Persistent coughing Rationale: A persistent cough can indicate that the distal end of the NG tube has moved into the respiratory tract. The pt should report this finding to nurse immediately because this is a risk for aspiration

A nurse is caring for a patient who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the patient with feeding? A) Provide the patient with a straw B) Offer the patient thin fluids C) Elevate the head of the bed 45 to 90 degrees D) Place food in the weaker side of the mouth

C) Elevate the head of the bed 45 to 90 degrees The client's head should be sufficiently elevated to prevent aspiration. A. Clients who have dysphagia cannot always control the amount of fluid they take in through a straw. Therefore, it can increase their risk for aspiration. B. The client's head should be sufficiently elevated to prevent aspiration. D. For clients who have unilateral weakness, it is best to place food in the stronger side of the mouth.

Which of the following strategies for enhancing the intake of healthful foods is appropriate for an adolescent? A) Encouraging the adolescent to consume snack foods with the grains food group B) Permitting the adolescent to skip breakfast to enhance appetite at later meals C) Making healthful food choices more convenient and available for the adolescent D) Allowing the adolescent complete autonomy in making food choices

C) Making healthful food choices more convenient and available for the adolescent A. The dairy, fruits, and vegetables food groups are the best choices for snack food for adolescents. B. Skipping meals is not a healthy alternative because it increases the risk of hypoglycemia, which in turn can lead to increased hunger and overeating. D. Peer influence could lead the adolescent to consume too much fast food and unhealthful snacks. Parents can have a positive influence on an adolescent's diet by using strategies such as restricting the amount of unhealthful food choices in the home.

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube? A) Levin B) Sengstaken-Blakemore C) Salem Pump D) Ewald E) Dobhoff tube

C) Salem pump (A salem pump is the only type of tube that allows for continuous suction. Salem sump tube is used for continuous suction to decompress the stomach. The tube has two lumens; one removes gastric contents and the other serves as an air vent. The vent allows air to enter the stomach, allowing the tube to float freely and preventing damage to the gastric mucosa.) **Levin tube: single lumen **Sengstaken-Blakemore: used in ER medicine; has an inflatable balloon that applies internal pressure to prevent or stop esophageal or gastrointestinal bleeding **Ewald tube: one-way stomach pump; is inserted orally and is used to irrigate the stomach in cases of active bleeding. **Dobhoff tube: A Dobhoff tube provides nasoduodenal feedings for clients who have impaired swallowing or require enteral feedings.

A nurse is performing a nutritional assessment. When obtaining and interpreting anthropometric values, the nurse should recognize which of the following? A) Isolated measurements of height and weight are of greater significance than changes over time B) A weight increase of 4 lbs in a patient with renal failure indicates retention of 1,000 mL of fluid C) The patient should be weighed on the same scale at the same time each day D) The ratio of height-to-weight circumference is the most accurate way to identify obesity

C) The patient should be weighed on the same scale at the same time each day **Weighing a patient on the same scale at the same time of day provides the most consistent data for gauging trends in the patient's weight, as shifts in fluid intake and output can alter weight significantly. The patient should also be weighed with the same amount of clothing and/or linen each time. A. Changes in values for an individual over time are of greater significance than isolated measurements because they show trends that provide more information about the patient's health status. B. A 2-lb weight increase reflects retention of 1,000 mL of fluid. D. Obesity is identified by multiple factors, particularly body mass index. Height-to-wrist circumference is an indicator of body-frame size.

The most reliable method for verifying initial placement of a small-bore feeding tube is by A) measuring the pH gastric aspirate B) auscultating the epigastric area while injecting air C) obtaining an abdominal XR D) Placing the open end of the tube in a cup of water

C) obtaining an abdominal XR Obtaining an x-ray is the only reliable method for verifying initial placement of a small-bore feeding tube. Gastric contents are acidic, with a pH from 1 to 4. A pH above 6 is an indication that the distal end of the tube can be in the respiratory tract or in the intestines. This method can be used to confirm placement of the tube; however, another method is used for verifying initial tube placement. Auscultation is no longer considered a valid method of determining tube placement. With this method, there is no guarantee the tube is in the client's stomach and not in their lung. Bubbling after the tube is placed in water might indicate that the tube has passed through the larynx into the trachea; however, this action can cause aspiration.

A nurse is teaching a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs nasogastric tube intubation for gastric decompression? A. A 6-year-old child who ingested a toxic substance B. A 60-year-old client who has a gastrointestinal hemorrhage C. A 40-year-old client who has a postoperative bowel obstruction D. A 20-year-old client who has malabsorption syndrome

C. A 40-year-old client who has a postoperative bowel obstruction Rationale: A client who has a postoperative bowel obstruction should have a nasogastric tube inserted for decompression to remove gastric secretions. This will assist in relieving abdominal distention, nausea, & pain. A. A client who ingested a toxic substance should have a nasogastric tube inserted for gastric lavage within 1 hr of ingestion. Gastric lavage is used to irrigate the stomach in cases of poisoning. B. A client who has a gastrointestinal hemorrhage should have a nasogastric tube inserted for compression. Gastric compression is an internal application of pressure caused by inflating a balloon. This can assist in stopping or preventing gastrointestinal hemorrhage. D. A client who has malabsorption syndrome should have a nasogastric tube inserted for enteral feedings.

A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? A. A client who has a paralytic ileus B. A client who has recently experienced facial trauma C. A client who has dysphagia D. A client who has a decreased appetite

C. A client who has dysphagia Rationale: The nurse should identify that a client who is unable to swallow oral nutrition can benefit from enteral feedings.

When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures? A) Do not give the child peanut butter B) Have the child drink 28 to 32 oz of milk daily C) Give the child 8 to 12 oz of fruit juice daily D) Do not offer the child raw vegetables

D) Do not offer the child raw vegetables Raw vegetables, as well as hot dogs, grapes, nuts, popcorn, and candy, have been implicated in choking deaths and should be avoided at least until the child is 3 years old. A. This is a recommendation for infancy, because peanuts and peanut butter carry a high risk of severe allergic reactions. Once it has been determined that the child does not have multiple food allergies, peanut butter is an attractive source of protein for children. B. More than 24 oz of milk daily in lieu of other foods may result in iron deficiency anemia. C. Juice should be limited to 4 to 6 oz per day because it is high in sugar content.

Which of the following is the primary purpose for asking a patient to keep a 3- to 7-day food diary? A) To allow the patient to rely on health professionals to identify problem areas B) To determine any changes in the patient's appetite C) To evaluate any significant changes in body weight D) To assess the pattern of intake and compare with daily reference intakes

D) To assess the pattern of intake and compare with daily reference intakes A time period of 3 to 7 days is an adequate amount of time for assessing dietary habits and patterns, and thus, the adequacy of the client's nutritional intake.

A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? A. Flush the feeding tube with 30 mL of water. B. Add blue food coloring to the enteral formula. C. Ensure the formula is at room temperature. D. Place the client in Fowler's position.

D. Place the client in Fowler's position. Rationale: Positioning a client in Fowler's position during a tube feeding can reduce the risk of regurgitation, which can lead to aspiration. If Fowler's is uncomfortable or contraindicated for the client, elevate the head of the client's bed to at least 30°.

To determine the length of a nasointestinal (NOTE INTESTINAL) tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe & from the earlobe to the ... A. Umbilicus B. Xiphoid process C. Manubrium plus 10 to 20 cm more D. Xiphoid process plus 20 to 30 cm more

D. Xiphoid process plus 20 to 30 cm more Rationale: Measuring from the tip of nose to earlobe to xiphoid process approximates the distance from nose to stomach for 98% of clients. For duodenal or jejunal placement, an additional 20 to 30 cm is required. Measuring from the tip of the client's nose to the earlobe to the xiphoid process only approximates the distance from the nose to the stomach.

A nurse is caring for a client who has a significant risk of aspiration and requires nutritional support for about 2 weeks because they are unable to consume adequete nutrients orally. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe? Nasogastric tube Nasointestinal tube Percutaneous endoscopic gastrostomy tube Percutaneous endoscopic jejunostomy tube

Nasointestinal tube A nasointestinal tube is recommended for clients at a high risk of aspiration who require short-term feedings of less than 4 weeks. **Nasogastric tubes are contraindicated for clients at high risk of aspiration. Therefore, another tube should be placed. Percutaneous endoscopic gastrostomy (PEG) tubes are indicated for long-term use in clients. Therefore, another tube should be placed. A percutaneous endoscopic jejunostomy tube is indicated for clients who require enteral feedings for more than 4 weeks. Therefore, another tube should be placed.

a nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. The client's food had a total of 72g of carbohydrates and 9g of fiber. How many net carbohydrates did the client consume? - 81 - 63 - 8 - 72

- 63 To calculate net carbohydrates, use the following equation: Total Carbohydrates - (Fiber + Sugar Alcohols if applicable) = Net Carbohydrates. In this case, 72 g carbohydrates - 9 g fiber = 63 net carbohydrates.

Nasogastric tube feedings are an appropriate choice for a patient who A) has a paralytic ileus B) has recently experienced facial trauma C) is postoperative following laryngectomy D) Has pancreatitis

C) is postoperative following laryngectomy (immediately following removal of the larynx, patients typically receive IV fluids or parenteral nutrition until the gastrointestinal tract recovers from anesthesia. Then, a nasogastric tube is inserted and left in place for about 7 to 10 days to provide enteral feedings until swallowing is safe and adequate.)

Which of the following dietary modifications should an adolescent engaging in sports implement? A) In crease fats to 30% to 40% of daily kilocalories B) Drink water before and after sports activity C) Keep protein intake at the same level D) Decrease carbohydrates to 30% to 40% of daily kilocalories

B) Drink water before and after sports activity An adolescent should drink water before and after sports activities to prevent dehydration. A. Fat needs are not increased for adolescents who participate in sports. C. Protein should be increased to 1.0 to 1.5 g/kg/day. D. The acceptable macronutrient range for carbohydrates is 45% to 65% of total calories.

When using a chilled normal saline solution during gastric lavage, the nurse should watch for which of the following complications?

Hypothermia (Iced normal saline can cause a rapid loss of electrolytes)

a nurse is reviewing a client's medical record and notes that their BMI is 25.5. how should the nurse interpret this finding? - the client is overweight - the client is underweight - the client's BMI is within the normal range - the client is obese

- the client is overweight According to the Body Mass Index (BMI) chart, a client who has BMI between 25 and 29.9 is considered overweight. Therefore, the nurse should identify that a client who has a BMI of 25.5 is in the overweight category. According to the BMI chart, a client who has a BMI below 18.5 is considered underweight. According to the BMI chart, the normal range for BMI is between 18.5 to 24.9. According to the BMI chart, a client who has a BMI above 30 is considered obese.

An older adult patient in a long-term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this patient? A) Encourage him to go to the dining room at meal times to talk with other patients. B) Suggest that he watch TV while his feedings are being administered C) Remind him that he can have visitors after his feeding administration D) Ask the facility chaplain to speak with him Encourage him to go to the dining room at meal times to talk with other patients.

A) Encourage him to go to the dining room at meal times to talk with other patients. By encouraging the resident to maintain a normal schedule and social interactions, the nurse is helping to promote socialization and reverse patterns of isolation. Although visitation policies vary at every facility, generally visitors are permitted during meal times in long-term care facilities. However, this intervention will not improve the situation if the client does not have a family and social network outside of the facility. The nurse should not contact the chaplain without first consulting with the client.

Which of the following interventions should a nurse use at mealtimes for a patient who has visual deficits? A) Identify the food locations as though the plate were a clock B) Direct the order in which food items are consumed C) Have the patient tilt her head forward while eating D) Avoid talking to the patient during mealtime

A) Identify the food locations as though the plate were a clock Telling the patient, for example, that the chicken is at 9 o'clock and the broccoli is at 12 o'clock helps orient her to the items on the plate and thus facilitates independence in eating. B. The patient should direct the order of food as well as the speed at which to eat it. Visual deficits should not affect these personal choices. C. This intervention is recommended to facilitate swallowing in patients who have dysphagia, not visual impairment. D. Mealtime is a social activity. The nurse should converse with the patient or invite visitors to join the patient for meals.

A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A) Inspect the oropharynx with a penlight and a tongue blade B) Obtain an x-ray examination of the chest and abdomen C) Tape the tube securely in place with a tube holder device D) Aspirate Gastric contents

A) Inspect the oropharynx with a penlight and a tongue blade The first action the nurse should take when using the airway, breathing, circulation approach to client care is inspect the client's oropharynx with a penlight and a tongue blade to check for kinks and to ensure the tube is not coiled in the client's airway. If this occurs, the nurse should pull back on the tube and try reinserting. Other actions come after.

A nurse inserting a nasogastric tube asks the pt to flex her head toward her check after the tube passes through the nasopharynx. The action facilitates proper insertion of the tube by A) closing off the glottis B) preventing curling of the tube in th emouth C) allowing the patient to breath through her mouth D) opening the esophageal sphincter

A) closing off the glottis This action prohibits the tube from entering the trachea by closing it off and opening the esophagus.

A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding? A. Limit the time the formula hangs to 8 hr. B. Flush the tube every 8 hr. C. Deliver the formula at a brisk rate D. Allow the feeding bag to empty before refilling it

A. Limit the time the formula hangs to 8 hr. Rationale: Formula that hangs longer than 12 hr for an open system and 48 hr for a closed system is at risk for spoilage of the formula or bacterial contamination, typically manifested as diarrhea.

A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? Select all that apply. A) active bowel sounds B) passing flatus C) Increase gastric secretions D) Patient's report of nausea E) Increased abdominal distention

D) Patient's report of nausea E) Increased abdominal distention (Tubes connected to suction decompress the GI tract. This is needed when peristalsis is absent. If gastric secretions (feces) are unable to move through the GI tract and if the nasogastric tube is unable to evacuate the stomach due to an occlusion, abdominal distention, nausea, and vomiting will result.)