PP Chapter 46. Urinary Elimination

23. A client has been receiving tube feedings and is tolerating them very well. The health care provider determines that the rate of the intermittent tube feedings may be advanced. The nurse prepares to: 1 Increase the feedings by 50 mL/day 2 Start an isotonic formula at half strength 3 Infuse a bolus feeding over 5 to 10 minutes 4 Begin feedings with 250 to 500 mL at each interval

ANS: 1 When a client is tolerating tube feedings well, the nurse should expect the health care provider to order the feedings to be increased by 50 mL/day to achieve needed volume and calories in six to eight feedings. Formula is started at full strength for isotonic formulas. Intermittent feedings are allowed to infuse over at least 20 to 30 minutes. Feedings should be begun with no more than 150 to 250 mL at one time. PTS: 1 DIF: A REF: 1123 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

11. A client is seen in the outpatient clinic for follow-up of a nutritional deficiency. In planning for the clients dietary intake, the nurse includes a complete protein, such as: 1 Eggs 2 Oats 3 Lentils 4 Peanuts

ANS: 1 A complete protein contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Eggs and meats are examples of complete proteins. Incompleteproteins lack one or more of the nine essential amino acids and include oats (cereals) and legumes (lentils and peanuts). PTS: 1 DIF: A REF: 1087 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

24. The nurse is aware that there are medications that are taken that alter the clients taste and may influence the dietary intake. In reviewing the medications taken by the clients on the unit, the nurse will consult with the nutritionist to develop a palatable meal plan for the client taking: 1 Ampicillin 2 Morphine 3 Furosemide 4 Acetaminophen

ANS: 1 Ampicillin may cause an alteration in taste. Opiates, such as morphine, cause decreased peristalsis and may result in constipation. Decreased drug absorption may occur when diuretics, such as furosemide, are administered with food. Decreased acetaminophen absorption may occur if administered with food. Overdose of acetaminophen is associated with liver failure. Morphine, furosemide, and acetaminophen do not affect the clients sense of taste. PTS: 1 DIF: C REF: 1097 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity Basic Care and Comfort/Nutrition and Oral Hydration

36. The nurse is questioning a newly admitted client regarding his dietary history. Which of the following questions asked by the nurse is most likely to secure additional pertinent information regarding the clients statement, I think Im allergic to peanuts? 1 What happens when you eat peanuts? 2 What makes you think you are allergic to peanuts? 3 When did you first notice this sensitivity to peanuts? 4 A peanut allergy is very serious; how do you manage to avoid them?

ANS: 1 Asking the client to describe the reactions to a particular food allows for a more thorough discussion than does any of the other options. Some options are more directed at the management rather than securing additional information regarding the reaction itself. PTS: 1 DIF: C REF: 1101 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

32. Which of the following statements reflects the best understanding of the benefits of breast- feeding related to the infants health and wellness? 1 My husband and I both have food allergies, but she wont be allergic to my breast milk. 2 The antibodies she gets will help keep her immunized from many illnesses for up to her first birthday. 3 I can spend so much more time with her because I have to devote my attention to her while I nurse. 4 Its so convenient, no formula preparation, no bottles to wash and fill, no packing for outings; its great.

ANS: 1 Breast-feeding benefits include the following: reduced food allergies and intolerances; fewer infant infections; easier digestion; convenient; always correct temperature, available, and fresh; economical, because it is less expensive than formula; and increased time for mother and infant interaction. The other options are not incorrect but do not focus on health benefits for the infant as directly as the answer. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

15. Which of the following would the nurse expect to see offered on a full liquid diet? 1 Custard 2 Pureed meats 3 Soft fresh fruit 4 Canned soup

ANS: 1 Custard is included in a full liquid diet. Pureed meats are allowed in a pureed diet, not a full liquid diet. Soft fresh fruit is not included in a full liquid diet. Fresh fruit is often part of a high- fiber diet. Cooked or canned fruits are allowed on a mechanical soft diet. Canned soup is not part of full liquid diet because it may contain noodles or rice or vegetables. Soups are allowed on a mechanical soft diet. PTS: 1 DIF: A REF: 1111 OBJ: Comprehension TOP: Nursing Process: Planning

20. The client is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the client is feeding self-care deficit related to unilateral weakness. An appropriate technique for the nurse to use when assisting the client with feeding is to: 1 Place food in the unaffected side of the mouth 2 Place the client in semi-Fowlers position 3 Have the client use a straw 4 Use thinner liquids

ANS: 1 If the client has unilateral weakness, the nurse should place food in the stronger side of the mouth. The client should be positioned in an upright, seated position to prevent aspiration.Clients with unilateral weakness often have difficulty using a straw. Thickened liquids are often tolerated better and will help prevent aspiration, because clients with impaired swallowing often choke more with thin liquids. PTS: 1 DIF: A REF: 1110 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

3. Besides being pivotal in the growth, maintenance, and repair of body tissue, protein plays a significant role in the bodys ability to: (Select all that apply.) 1 Produce T cells 2 Manage bleeding 3 Produce carbon dioxide 4 Maintain blood pressure 5 Manage waste production 6 Transport drugs systemically

ANS: 1, 2, 4, 6 Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue in growth, maintenance, and repair. Collagen, hormones, enzymes, immune cells, DNA, and RNA are all made of protein. In addition, blood clotting, fluid regulation, and acid- base balance require proteins. These proteins transport nutrients and many drugs in the blood. There is not a direct connection between the other options and protein. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

2. A client is suspected of having a fat-soluble vitamin deficiency. To assist the client with this deficiency, the nurse informs the client that: 1 More exposure to sunlight and drinking milk could solve your nutritional problem 2 Eating more pork, fish, eggs, and poultry will increase your vitamin B complex intake 3 Increasing your protein intake will increase your negative nitrogen imbalance 4 Decreasing your triglyceride levels by eating less saturated fats would be a good health intervention for you

ANS: 1 The fat-soluble vitamins are A, D, E, and K. With the exception of vitamin D, which can be obtained through exposure to sunlight, these vitamins are provided through dietary intake, including fortified milk. The B vitamins are not fat-soluble; they are water-soluble vitamins. Increasing protein intake will improve (decrease) a negative nitrogen imbalance, not increase it. Furthermore, increasing protein intake does not address the problem of a fat-soluble vitamin deficiency. PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

10. Before inserting a small-bore nasogastric tube for enteral nutrition, the nurse correctly tells the client: 1 The tube will feel uncomfortable and may make you gag at times when I am inserting it 2 We will mark this tube from the end of your nose to your umbilicus to obtain the right length for insertion 3 Please hold your breath when I insert this small tube through your nose down into your stomach 4 Please tilt your head back after the tube passes the nasopharynx.

ANS: 1 The procedure should be explained to the client, including how to communicate during intubation by raising his or her index finger to indicate gagging or discomfort. This will help reduce anxiety and help the client to assist in insertion. The length of the tube to be inserted is measured from the tip of the nose, to the earlobe, to the xiphoid process of the sternum. The client should be told to mouth-breathe and swallow during the procedure. The client should not hold his or her breath. The nurse should instruct the client to flex the head toward the chest after the tube has passed the nasopharynx. PTS: 1 DIF: C REF: 1113 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

4. The nurse is discussing breast-feeding with a pregnant mother who is being seen for a routine obstetrical visit. Which of the following should the nurse include as positive effects/outcomes of breast-feeding? (Select all that apply.) 1 Good source of antibodies 2 Convenient source of nutrition 3 Economical source of nutrients 4 Minimal digestive system upsets 5 Less risk related to food allergies 6 Encourages family-infant bonding

ANS: 1, 2, 3, 4, 5 Benefits of breast-feeding include reduced food allergies and intolerances; fewer infant infections; easier digestion; convenient; always correct temperature, available, and fresh; economical, because it is less expensive than formula; and increased time for mother and infant interaction, although it does not contribute to family-infant bonding. PTS: 1 DIF: A REF: 1094 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

2. Which of the following clients has an identified factor that is affecting the clients energy requirements? (Select all that apply.) 1 A 27-year-old diagnosed anorexic client 2 A 21-year-old college football quarterback 3 A 73-year-old recovering from hip surgery 4 A 39-year-old who is currently menstruating 5 A 4-year-old with a temperature of 102.2 F rectally 6 A 50-year-old diagnosed with chronic depression

ANS: 1, 2, 3, 4, 5 Factors such as age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, or thyroid function affect energy requirements. There is no direct connection between depression and energy requirements. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

1. The nurse is delegating the feeding of an older adult client to ancillary personnel. Which of the following should the nurse include in the instructions as possible warning signs of dysphagia (difficulty swallowing)? (Select all that apply.) 1 Delay in swallowing food 2 Easily triggered gag reflex 3 Absence of a gag reflex 4 Uncoordinated speech 5 Disinterest in eating 6 Pocketing food

ANS: 1, 2, 3, 4, 6 Signs of dysphagia include the following: cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag reflex, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia. PTS: 1 DIF: A REF: 1092 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

7. Which of the following assessment findings in an older adult increases the individuals risk for poor nutrition? (Select all that apply.) 1 Living on a Social Security income check 2 Did not graduate from high school 3 Is easily tired by activity 4 Living in a group home 5 Chronically depressed 6 Recently widowed

ANS: 1, 2, 3, 5, 6 Malnutrition in older adults has multiple causes, such as income, educational level, physical functioning level to meet activities of daily living (ADLs), loss, dependency, loneliness, and transportation. Living in a managed environment is not a risk factor for poor nutrition.

6. Older adults are at an increased risk for dehydration from a variety of risk factors that include a decreased thirst drive. Which of the following should a nurse include in a discussion with members of a senior center regarding the signs of dehydration? (Select all that apply.) 1 Dry, hot skin 2 Memory lapses 3 Dry, cracked lips 4 Weak, slow pulsec 5 Physical weakness 6 Decreased urination

ANS: 1, 2, 3, 5, 6 Symptoms of dehydration in older adults include confusion; weakness; hot, dry skin; furrowed tongue; rapid pulse; and high urinary sodium level. PTS: 1 DIF: A REF: 1096 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

12. According to the food guide pyramid, vegetables should be included in the average adults diet as: 1 1 to 3 servings per day 2 2 to 4 servings per day 3 3 to 5 servings per day 4 6 to 11 servings per day

ANS: 3 According to the food guide pyramid, the average adults diet should include 3 to 5 servings of vegetables per day. According to the food guide pyramid, the average adults diet should include 2 to 4 servings per day of fruit and 2 to 4 servings per day of grains. PTS: 1 DIF: A REF: 1091 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

40. The nurse is caring for a 6-kg 4-month-old infant who is hospitalized with a respiratory infection. The nurse knows that an infant this age needs approximately 108 kcal/kg of body weight. The nurse also understands that human breast milk provides approximately 20 kcal/oz. About how much breast milk does the nurse need to feed the infant every 4 hours in order to provide enough to meet the infants nutritional needs? 1 4.5 ounces 2 5.5 ounces 3 6.5 ounces 4 7.5 ounces

ANS: 2 6 kg x 108 kcal/kg/day = 648 kcal/day; 648 kcal/day 20 kcal/oz = 32.4 oz/day; 32.4 oz/day 24 hr/ day = 1.35 oz/hr; 1.35 oz/hr x 4 hours = 5.4 ounces every 4 hours. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

19. Which of the following is accurate nutritional information that the nurse should share with the parents of an adolescent child? 1 Girls require less protein. 2 Boys require additional iron. 3 Vitamin B needs are decreased. 4 Energy and caloric needs are decreased.

ANS: 2 Adolescent boys require additional iron for muscle development. Daily requirements of protein increase for both adolescent boys and adolescent girls. B complex vitamins are needed to support heightened metabolic activity. Energy and caloric needs are increased to meet greater metabolic demands of growth during the adolescent period. PTS: 1 DIF: A REF: 1093 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

43. A 68-year-old female client tells the home care nurse that she is worried about her 70-year- old husband because he does not eat as much as he used to when he was younger. Which of the following is the best response from the nurse? 1 Perhaps your husband needs to have his thyroid level checked. 2 Your husband is at an age when his metabolism is slowing down and his energy requirements arent as great as they were when he was younger. 3 Are you fixing the foods that he likes? 4 That should cut down on your grocery bill.

ANS: 2 Adults 65 years and older have a decreased need for energy as metabolic rate slows with age. However, vitamin and mineral requirements remain unchanged from middle adulthood. PTS: 1 DIF: B REF: 1094 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

4. The school nurse suspects that a junior high student may have anorexia nervosa. This eating disorder is characterized by: 1 A lack of control over eating patterns 2 Self-imposed starvation 3 Binge-purge cycles 4 Excessive exercise

ANS: 2 Anorexia nervosa is characterized by self-imposed starvation. Bulimia nervosa is characterized by a lack of control over eating patterns and binge-purge cycles. Clients with bulimia may exercise excessively to prevent weight gain. PTS: 1 DIF: A REF: 1093 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

8. Which of the following should the nurse do first when introducing a feeding to a client with an indwelling gavage tube? 1 Irrigate the tube with normal saline solution. 2 Check to see that the tube is properly placed. 3 Place the client in a supine position. 4 Introduce some water before giving the liquid nourishment.

ANS: 2 Before introducing a feeding through an indwelling gavage tube for enteral nutrition, it is essential that the nurse check to see that the tube is properly placed. It is not necessary to irrigate the tube with normal saline. The clients head should be elevated 30 to 45 degrees to help prevent the chance of aspiration. The tube may be flushed with 30 mL of water before initiating the feeding. However, the nurse should first verify correct tube placement. PTS: 1 DIF: C REF: 1113-1116 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

44. The nurse is counseling a 64-year-old client that it is important to eat plenty of fruits and vegetables, but the client should avoid which of the following because it can inhibit the absorption of some drugs? 1 Oranges 2 Grapefruit 3 Pineapple 4 Asparagus

ANS: 2 Caution older adults to avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs. PTS: 1 DIF: C REF: 1086 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

37. The nurse is counseling a client undergoing chemotherapy. The client has shared with the nurse that the client does not have much of an appetite and is worried about not getting enough nutrients. Which of the following statements by the nurse addresses the clients concerns? 1 Let me share information regarding how a high-calorie diet can help prevent you from losing weight. 2 Let me share information about high-nutrient-density foods to help you make choices. 3 You need to avoid carbohydrates in your diet. 4 Your body needs a lot of protein right now to prevent muscle loss.

ANS: 2 Foods are sometimes described according to their nutrient density, the proportion of essential nutrients to the number of kilocalories. High-nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. The client did not express a concern about weight loss but is asking about nutrition. Protein provides energy, but because of proteins essential role in growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. Each gram of carbohydrate produces 4 kcal and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. When there is sufficient carbohydrate in the diet to meet the energy needs of the body, protein is spared as an energy source. PTS: 1 DIF: B REF: 1111 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

42. One easy way that parents of teenagers can ensure that they are getting enough iodine in their diets to support the increased thyroid activity during adolescence is to: 1 Give the child a multivitamin daily 2 Use iodized table salt 3 Keep fresh fruit and vegetables on hand for snacks 4 Serve red meat at least once a week

ANS: 2 Iodine supports increased thyroid activity, and use of iodized table salt ensures availability. PTS: 1 DIF: B REF: 1092 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

17. A client is diagnosed with a peptic ulcer and has come to the primary health care provider for a follow-up visit. The client asks the nurse what foods are safe to add to his diet. An appropriate response by the nurse is to inform the client that which of the following may be added to the diet? 1 Citrus juices 2 Green vegetables 3 Frequent glasses of milk 4 Unlimited decaffeinated coffee

ANS: 2 The client diagnosed with a peptic ulcer may be allowed to add green vegetables to his diet. The client with a peptic ulcer should avoid foods that increase stomach acidity, such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and certain seasonings (hot chili peppers, chili powder, black pepper). Smoking, alcohol, and aspirin are also discouraged. PTS: 1 DIF: A REF: 1126 OBJ: Comprehension

6. The nurse should offer a client who has had throat surgery which of the following? 1 Chicken noodle soup 2 Ginger ale 3 Oatmeal 4 Hot tea with lemon

ANS: 2 The client who has had throat surgery should first be offered clear liquids. If the client tolerates clear liquids, then he or she may be advanced to a full liquid diet, and then to a mechanical soft diet. Because the client had throat surgery, excoriating liquids such as citrus juices should be avoided. Also, to be able to assess for bleeding, red or dark liquids should be avoided (e.g., apple juice or ginger ale is recommended rather than grape or cranberry juice). The client should begin oral intake with clear liquids. Neither chicken noodle soup nor oatmeal is included on a clear liquid diet. Hot tea with lemon would not be recommended. Liquids should not be hot or contain citrus, which could cause pain or excoriation and possible bleeding at the surgical site. PTS: 1 DIF: A REF: 1106 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

39. The nurse is caring for a 5-kg 8-month-old infant admitted to the hospital by the health care provider, who was concerned about the infants low weight. The infants birth weight was 3.5 kg. The nurse knows that on average an infant doubles his or her birth weight at what age? 1 2 to 3 months 2 4 to 5 months 3 6 to 7 months 4 8 to 9 months

ANS: 2 The infant usually doubles birth weight at 4 to 5 months and triples it at 1 year. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

9. The nurse is caring for a client who is receiving parenteral nutrition (PN). Which of the following is an appropriate nursing intervention when administering parenteral nutrition to a client? 1 Begin the infusion rates at 100 to 150 mL/hour. 2 Maintain a consistent infusion rate. 3 Change the infusion tubing once a week. 4 Monitor protein levels daily.

ANS: 2 The infusion should be maintained at a consistent rate. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up, because this could lead to osmotic diuresis and dehydration. An infusion should not be discontinued abruptly, because it may cause hypoglycemia. An initial rate of 40 to 60 mL/hr is recommended. To avoid infection, the infusion tubing should be changed every 24 hours with lipids and every 48 hours when lipids are not infused. Protein levels do not need to be monitored daily. The client should be weighed daily until maximum administration rate is reached and maintained for 24 hours; then weigh the client 3 times per week. PTS: 1 DIF: C REF: 1121 OBJ: Analysis

35. Which of the following statements by an older adult shows the most need for follow-up regarding the risk for dehydration in this age-group? 1 I have a glass of water with each meal and whenever Im thirsty. 2 As long as I drink whenever Im thirsty, I think Ill be well hydrated. 3 I try not to drink much after dinner so I dont have to get up to urinate at night. 4 I limit my coffee and tea drinking because I dont think they are particularly good for you.

ANS: 2 Thirst sensation diminishes with age, leading to inadequate fluid intake or dehydration. The remaining options deal more with the effects of fluid consumption than with the risk for dehydration. PTS: 1 DIF: C REF: 1094 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

38. A 41-year-old female client has been dieting to lose weight. Which of the following statements indicates that the client needs additional teaching regarding a healthy weight-loss plan? 1 I have based my diet on the food pyramid. 2 I am planning to lose between 1 and 2 pounds per week. 3 I need to eliminate all fat from my diet. 4 I plan to begin an exercise program as soon as I see my health care provider.

ANS: 2 Total fat intake should be between 20% and 35% of total calories with most fats coming from polyunsaturated or monounsaturated fatty acids. The Food Guide Pyramid is a basic guide for buying food and meal preparation. This basic system provides for diets ranging from 1600 to 2800 kcal/day. Losing weight at a slow rate is healthier than taking it off quickly. In general, when energy requirements are completely met by kilocalorie intake in food, weight does not change. When the kilocalories ingested exceed a persons energy demands, the individual gains weight. If the kilocalories ingested fail to meet a persons energy requirements, the individual loses weight. PTS: 1 DIF: B REF: 1109 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

46. The nurse caring for a 55-year-old male client knows that due to his religious beliefs he is most likely a vegetarian. Which of the following religions encourage vegetarianism? 1 Church of Jesus Christ of Latter-Day Saints 2 Seventh-Day Adventist 3 Judaism 4 Pentecostal

ANS: 2 Vegetarian or ovolactovegetarian diets are encouraged in followers of the Seventh-Day Adventist Church. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration MULTIPLE RESPONSE

5. Which of the following factors are believed to contribute to the prevalence of overweight children seen in America today? (Select all that apply.) 1 Unavailability of high-nutrient-density foods 2 Reliance on food as a stress-coping mechanism 3 Decline in an interest in physically active hobbies 4 Reliance on fast foods for major portion of daily diet 5 Increased interest in passive, technology-driven activities 6 Reduced supervision in the home, especially during after- school hours

ANS: 2, 3, 4, 5, 6 A combination of factors contributes to the problem, including a diet rich in high-calorie foods, inactivity, genetic predisposition, use of food as a coping mechanism for stress or boredom, and family and social factors. There is not a scarcity of healthy foods in this country. PTS: 1 DIF: C REF: 1094 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

21. A nasogastric tube is inserted in order for the client to receive intermittent tube feedings. An initial chest x-ray examination is done to confirm placement of the tube in the stomach. After the x-ray confirmation, the most reliable method of checking for tube placement is for the nurse to: 1 Place the end of the tube in water and observing for bubbling 2 Auscultate while introducing air into the tube 3 Measure the pH of the secretions aspirated 4 Ask the client to speak

ANS: 3 After the x-ray confirmation, the next best method involves testing the pH of the feeding tube aspirate and observing the appearance of the aspirate. A properly obtained pH of 0 to 4 is a good indication of gastric placement. Placing the end of the tube in water and observing for bubbling is not an accurate method of checking for tube placement. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus can transmit a sound similar to that of air entering the stomach. Asking the client to speak as a method of checking for tube placement has a high degree of inaccuracy. There have been cases reported in which clients have been able to speak despite placement of feeding tubes in the lung.

33. The nurse and the mother of an infant are discussing the introduction of solid foods into her childs diet. Which of the following statements made by the mother reflects the best understanding of the most appropriate manner to introduce new foods? 1 Both my husband and I have allergies, so I am very cautious about introducing anything new into her diet. 2 Im a fussy eater, and so are my other children; but I will offer her a variety of foods so she will have a good appetite. 3 Ill start with nonwheat cereal and then vegetables; one new food a week so I can see if something doesnt agree with her. 4 My other children just loved solids and really were a joy to feed; I expect she will be as receptive to new foods as they were.

ANS: 3 Caregivers introduce new foods one at a time, approximately 4 to 7 days apart to identify allergies. The other options are not as directly focused on the possibility of food allergies. PTS: 1 DIF: C REF: 1092 OBJ: Analysis TOP: Nursing Process: Evaluation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

18. When teaching the parents of a toddler about safe finger foods, the nurse suggests trying which of the following? 1 Nuts 2 Popcorn 3 Cheerios 4 Hot dogs

ANS: 3 Cheerios are an appropriate finger food for a toddler or preschool child. Nuts, popcorn, and hot dogs have been implicated in choking deaths and should be avoided. If hot dogs are given to this age child, they should be cut up into irregularly shaped pieces, such as long strips. PTS: 1 DIF: A REF: 1092 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

27. A nurse is discussing high-nutrient-density food selections with a client recovering from extensive partial-thickness burns. Which of the following statements by the nurse reflects the best understanding of this dietary concept? 1 Do you enjoy fresh fruits and vegetables? 2 Would you consider replacing soda with milk? 3 Your body requires lots of energy in order to heal itself, and that energy comes from nutrient-packed foods. 4 You need a great deal of energy, and youll get that by eating large volumes of food that can be turned into energy.

ANS: 3 High-nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. Low-nutrient-density foods, such as alcohol or sugar, are high in kilocalories but are nutrient poor. The remaining options either provide suggestions for food substitutes or provide a less informative explanation. PTS: 1 DIF: C REF: 1086 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

45. When menu planning for a newly diagnosed diabetic client who practices Judaism, the nurse should avoid which of the following dishes? 1 Vegetable beef soup 2 Chicken pot pie 3 Beef lasagna 4 Scrambled eggs

ANS: 3 Judaism prohibits the mixing of milk or dairy products with meat dishes, and the beef lasagna has both meat and cheese in it. PTS: 1 DIF: B REF: 1086 OBJ: Application TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

28. The nurse recognizes which of the following clients as being at greatest risk for a negative nitrogen balance? 1 A 10-year-old with an infected laceration on the left thumb 2 A 75-year-old who fell and experienced a mild concussion 3 A 40-year-old who has partial-thickness burns over 15% of his body 4 A 19-year-old who has lost 70 pounds in 7 months as a result of dieting

ANS: 3 Negative nitrogen balance occurs when the body loses more nitrogen than the body gains, for example, with infection, sepsis, burns, fever, starvation, head injury, and trauma. Although all these clients may be experiencing an increased nitrogen need for body repair, the burn client has the greatest need and so is at greatest risk for a negative nitrogen balance. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

13. When providing nutritional guidance, the nurse shares with the mother of an 8-year-old client that children of this age need to: 1 Increase their intake of B vitamins 2 Significantly increase iron intake 3 Maintain a sufficient intake of protein and vitamins A and C 4 Increase carbohydrates to meet increased energy needs

ANS: 3 School-age childrens diets should be carefully assessed for adequate protein and vitamins A and C. School-age children frequently fail to eat a proper breakfast and have unsupervised intake at school. An increase in B complex vitamins is needed to support heightened metabolic activity of the adolescent, and the pregnant woman has a need to significantly increase iron intake. Increased energy needs are expected in the adolescent period.

26. A nurse is discussing high-nutrient-density food selections with a client recovering from extensive partial-thickness burns. Which of the following statements by the client reflects the best understanding of this dietary concept? 1 Ill snack on things like sugar-free pudding and Jello. 2 Fried chicken and potato salad are my favorite comfort foods. 3 My wife has a wonderful recipe for low-calorie vegetable dip. 4 Its a good thing that I really enjoy salads and whole wheat breads.

ANS: 4 High-nutrient-density foods, such as fruits and vegetables, provide a large number of nutrients in relationship to kilocalories. Low-nutrient-density foods, such as alcohol or sugar, are high in kilocalories but are nutrient poor. The remaining options mention low-calorie and comfort food; they are not really discussing high-nutrient-density foods. PTS: 1 DIF: C REF: 1086 OBJ: Nursing Process: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

22. For the client who is receiving parenteral nutrition via a central venous catheter, the nurse recognizes that a priority is to: 1 Use sterile technique during the administration of the feedings 2 Maintain the initial infusion rate at no more than 40 to 60 mL/ hr 3 Complete the administration of the feeding within 12 hours 4 Have radiographic confirmation of the placement of the catheter

ANS: 4 After catheter placement, the catheter is flushed with saline or heparin until the position is radiographically confirmed. Aseptic technique, not sterile technique, is used during the administration of feedings. An initial rate of 40 to 60 mL/hr is recommended, and the rate is gradually increased. The rate of administration is not the priority. The nurse must first confirm correct placement of the catheter. A single container of PN should hang no longer than 24 hours; lipids no more than 12 hours. The nurse must first confirm correct placement of the catheter before any infusion is begun. PTS: 1 DIF: C REF: 1123 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

30. A client with a family history of cancer is discussing the effects of free radicals on body cells and tissue. Which of the following responses is the most therapeutic answer to the clients question, What can I do to protect against free radicals? 1 Eat foods like blueberries, oranges, almonds, and carrots; they fight free radicals. 2 I can give you some literature on which foods are highest in free-radical fighters. 3 Research seems to support the positive role vitamins A, C, and E play in neutralizing free radicals. 4 Foods that contain vitamins A, C, and E as well as beta- carotene seem to combat the effects of free radicals.

ANS: 4 Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers believe that oxidative damage increases a persons risk for various cancers. These vitamins include beta-carotene and vitamins A, C, and E. The remaining options oversimplify the response or give very unspecific information.

14. When assisting the client who practices Islam or Judaism with meal planning, the nurse knows that both religions share an avoidance of: 1 Alcohol 2 Shellfish 3 Caffeine 4 Pork products

ANS: 4 Clients who practice Islam or Judaism share an avoidance of pork in their diet. Clients who practice Islam avoid alcohol and caffeine but will eat shellfish. Clients who practice Judaism do not restrict alcohol or caffeine intake and only eat fish with scales. Seventh-Day Adventists also avoid shellfish. Mormons also avoid caffeine. PTS: 1 DIF: A REF: 1096 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

25. Food safety is a concern of a group of adults attending the community health clinic. The participants identify to the nurse that they have seen a lot of reports on television about Escherichia coli and how dangerous it can be. When asked where the bacteria comes from, the nurse responds that a potential source of E. coli is: 1 Sausage 2 Soft cheeses 3 Milk products 4 Ground beef

ANS: 4 E. coli may be contracted from undercooked meat, such as ground beef. Sausage is a potential source of botulism. Soft cheeses are a potential source of listeriosis, and milk products are a potential source of shigellosis. PTS: 1 DIF: A REF: 1109 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

5. A client is pregnant for the third time. In regard to her nutritional status, she should: 1 Limit her weight gain to a maximum of about 25 pounds 2 Approximately double her protein intake 3 Increase her vitamin A and milk product consumption 4 Increase her intake of folic acid

ANS: 4 Folic acid intake is particularly important for DNA synthesis and the growth of red blood cells. Inadequate intake may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. It is now recommended that women planning future pregnancies discuss preconception folic acid supplements. The recommended weight gain for pregnancy is 25 to 35 pounds for the woman of average weight. There is no need for the client to limit her weight gain to a maximum of 25 pounds on the basis of this being her third pregnancy. The client needs to increase her protein intake to 60 g during pregnancy; she does not need to double it. (This is an increase of approximately 20 g of protein.) Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes. The recommended intake of vitamin A does not increase over the nonpregnant state. Calcium intake increases from 800 mg to 1200 mg during pregnancy. PTS: 1 DIF: A REF: 1094 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

1. While doing a nutritional assessment of a low-income family, the community health nurse determines the familys diet is inadequate in protein content. The nurse suggests which of the following foods to increase protein content with little increase in the food budget? 1 Oranges and potatoes 2 Potatoes and rice 3 Rice and macaroni 4 Peas and beans

ANS: 4 For families on limited budgets, substitutes can be used. For example, bean or cheese dishes can often replace meat in a meal. Peas and lentils are also inexpensive food sources of protein. Oranges and potatoes are not high in protein content. Potatoes and rice are sources of carbohydrates, not protein. Rice and macaroni are carbohydrates and are not high in protein. PTS: 1 DIF: A REF: 1087 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

7. The nurse is discussing dietary intake with a client who is human immunodeficiency virus (HIV) positive. The nurse informs the client that the diet will include a: 1 Restriction of potassium, phosphate, and sodium 2 Reduction in carbohydrate intake 3 Decreased protein and increased folic acid intake 4 Reduction in fat with smaller, more frequent meals

ANS: 4 HIV-infected clients typically experience body wasting and severe weight loss. Restorative care for these clients focuses upon maximizing kilocalories and nutrients. Low-fat diets and small, frequent, nutrient-dense meals may be better tolerated. There is no need to restrict potassium, phosphate, and sodium in the client with HIV infection. The client with HIV infection does not need to reduce carbohydrate or protein or increase folic acid intake. PTS: 1 DIF: A REF: 1110 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort /Nutrition and Oral Hydration

41. Which of the following statements by a new mother indicates that the nurse needs to provide additional teaching before the client is discharged home with her infant? 1 I will be using infant formula, which will provide all the nutrition that my new baby needs. 2 I can feed my new baby every 3 to 4 hours when I get home. 3 I will need to sterilize all my babys bottles and nipples to make sure they dont have any germs. 4 I can put a few drops of honey in my babys formula to make it taste better.

ANS: 4 Honey and corn syrup are potential sources of botulism toxin. Infant formula provides all the nutrition that a newborn infant needs. Newborns need to be fed every 3 to 4 hours, and their bottles and nipples need to be sterilized. PTS: 1 DIF: B REF: 1092 OBJ: Application TOP: Nursing Process: Assessment MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

16. During an enteral tube feeding, the client complains of abdominal cramping and nausea. The nurse should: 1 Cool the formula 2 Remove the tube 3 Use a more concentrated formula 4 Decrease the administration rate

ANS: 4 If the client begins to experience abdominal cramping and nausea during an enteral tube feeding, the nurse should decrease the administration rate to increase tolerance. Administration of cold formula may cause abdominal cramping and nausea. The formula is best tolerated at room temperature. The nurse should not remove the tube if the client complains of abdominal cramping and nausea. The formula may need to be diluted if the client is complaining of abdominal cramping and nausea. PTS: 1 DIF: B REF: 1117 OBJ: Application TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

29. The nurse is discussing food selection with a client who recently experienced a partial- thickness burn over 20% of her body. The client expresses a reluctance to ingest a large amount of carbohydrates because she successfully lost 50 pounds and does not want to regain the weight. The most therapeutic response to the clients nutritional needs is: 1 Dont be concerned about regaining the weight until your burns have healed. 2 You need a huge amount of calories to heal, so there wont be a weight gain. 3 You will experience a nitrogen imbalance if there arent enough carbohydrates in your diet. 4 The extra carbohydrates will be utilized for energy so that your protein can be saved for repair of your skin.

ANS: 4 Negative nitrogen balance occurs when the body loses more nitrogen than the body gains; for example, with infection, sepsis, burns, fever, starvation, head injury, and trauma. Nutrition during this period needs to provide nutrients to put clients into positive nitrogen balance for healing. Carbohydrates are the main source of energy in the diet. The remaining options concentrate more on the weight gain issue than the energy need. PTS: 1 DIF: C REF: 1087 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

31. The nurse is discussing vitamin supplements with a client who is an amateur body builder. Which of the following statements by the nurse shows the greatest understanding concerning the risk for hypervitaminosis? 1 Vitamins are important to proper body building and repair, but be aware that you can overdose and harm yourself. 2 Fat-soluble vitamins are stored in the bodys fat reserves, so be careful not to take too much vitamins A, D, E, and K. 3 Water-soluble vitamins are not stored in the body like fat- soluble ones, so its less likely to overdose on vitamin C and the B complex. 4 I realize vitamin supplements are a factor in your training, but be aware of daily requirements so you dont overdose, especially the fat-soluble vitamins.

ANS: 4 The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils. The water-soluble vitamins, vitamin C and the B complex (which is eight vitamins), are not stored, so these need to be provided in the daily food intake. Although water-soluble vitamins are not stored, toxicity can still occur. The remaining option is not incorrect but is not as inclusive as the answer. PTS: 1 DIF: C REF: 1088 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

3. The client is diagnosed with malabsorption syndrome (celiac disease). In teaching about the gluten-free diet, the nurse informs the client to avoid: 1 Citrus fruits 2 Vegetables 3 Red meats 4 Wheat products

ANS: 4 The treatment of malabsorption syndromes, such as celiac disease, includes a gluten-free diet. Gluten is present in wheat, rye, barley, and oats. Citrus fruits, vegetables, and red meat do not contain gluten. PTS: 1 DIF: A REF: 1126 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration

34. The mother of a 25-month-old is discussing her concerns regarding her daughters eating habits with the nurse. The most therapeutic response to the mothers statement, She is such a fussy eater; it seems that she will only eat dry cereal and cheese is: 1 As long as she is eating a little from all the food groups and getting enough fluids, she will be all right 2 Her weight and height are right on target, so she must be getting what she needs to grow and develop 3 Dont expect her to start liking a variety of foods for several more months; just keep offering her what she likes 4 Its very common for toddlers to be picky eaters; try offering her food frequently, and offer high-nutrient-density snacks such as the cheese she likes

ANS: 4 Toddlers exhibit strong food preferences and become picky eaters. Small frequent meals consisting of breakfast, lunch, and dinner with three interspersed high-nutrient-density snacks help improve nutritional intake. The answer provides the most comprehensive response to the mothers statement because it provides both an explanation and a suggestion. PTS: 1 DIF: C REF: 1192 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration