Unit 5 - EAQ

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. The nurse receiving report should first: 1) Suggest that an antiemetic be prescribed 2) Change the feeding schedule to omit nights 3) Request that the type of solution be changed 4) Gather more data from the night nurse about the technique used

4

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets.

2

A client with a rigid and painful abdomen is diagnosed with a perforated peptic ulcer. A nasogastric tube is inserted and surgery is scheduled. Before surgery, the nurse should place the client in what position? 1. Sims 2. Flat-lying 3. Semi-Fowler 4. Dorsal recumbent

3

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to: 1. Promote gluconeogenesis. 2. Produce an anti-inflammatory effect. 3. Promote cell growth and bone union. 4. Decrease pain medication requirements.

3

A client has a body mass index (BMI) of 35 and verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by changing which dietary habits? 1) Decrease portion size and fat intake 2) Increase protein and vegetable intake 3) Decrease carbohydrate and fat intake 4) Increase fruits and limit fluid intake

1

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. The nurse explains that a PEG tube is preferred for administering a tube feeding because: 1. There is less chance of aspiration 2. This procedure does not require a pump 3. Self-administration of the feeding is possible 4. More tube feeding mixture can be given each time

1

Three days after admission to the hospital for a brain attack (cerebrovascular accident [CVA]), a client has a nasogastric tube inserted and is receiving continuous tube feedings. What should the nurse do to best evaluate whether the feeding is being absorbed? 1) Aspirate for a residual volume. 2) Evaluate the intake in relation to the output. 3) Instill air into the client's stomach while auscultating. 4) Compare the client's body weight with the baseline data.

1

The nurse identifies that the dietary teaching provided for a client with diabetes is understood when the client states, "My diet: 1) Should be rigidly controlled to avoid emergencies." 2) Can be planned around a wide variety of commonly used foods." 3) Is based on nutritional requirements that are the same for all people." 4) Must not include eating any combination dishes and processed foods."

2

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? 1) Empty feeding bag stays attached to the tubing. 2) Tube is flushed with air after medication is given. 3) Replacement of the tube is done on a weekly basis. 4) Head of the bed remains elevated after the feeding.

4

Which statement made by a client after attending a class on nutrition indicates an understanding of the importance of essential amino acids? 1) "Amino acids can be made by the body because they are essential to life." 2) "They come from the diet because they cannot be synthesized in the body." 3) "They are used in key processes essential for growth once they are synthesized by the body." 4) "Essential amino acids are required for metabolism, whereas the other amino acids are not."

2

A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. How should the nurse plan to meet this client's nutritional needs? 1. Stay with the client during meals 2. Take the client to the dining room 3. Bring the client a tray of finger foods 4. Talk with the client about the importance of nutrition

1

A nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. Instill the prescribed solution. Aspirate the contents of the stomach. Document the client's response to the procedure. Wash the hands. Verify the solution to be administered.

Wash the hands. Verify the solution to be administered. Aspirate the contents of the stomach. Instill the prescribed solution. Document the client's response to the procedure

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? 1. Keeps the area free of microorganisms. 2. Confines microorganisms to the surgical site. 3. Protects self from microorganisms in the wound. 4. Reduces the risk for growing opportunistic microorganisms.

1

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction? 1) Whole milk with oatmeal 2) Garden salad with olive oil 3) Tuna fish with a small apple 4) Soluble fiber cereal with skim milk

1

A client has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? (Select all that apply.) 1) Raisins 2) Squash 3) Carrots 4) Spinach 5) Apricots

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A nurse has just finished feeding a 4-year-old child through a nasogastric tube. In what position should the child be placed to help ensure retention of the feeding and prevent aspiration? 1. Supine 2. Semi-Fowler 3. Trendelenburg 4. Left side-lying

2

A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? 1. Bananas 2. Strawberries 3. Green beans 4. Sweet potatoes

2

The nurse is reviewing a teaching plan for a client that has been prescribed a 2-gram sodium diet. The plan should include which foods that are low in sodium? 1. Meat and fish 2. Fruits and juices 3. Milk and cheese 4. Dry cereals and grains

2

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1. Skin breakdown 2. Aspiration pneumonia 3. Retention ileus 4. Profuse diarrhea

2

A client is receiving a 2-gram sodium diet. The family asks whether they can bring snacks from home. The nurse suggests that they bring foods low in sodium such as: 1) Ice cream 2) Celery sticks 3) Fresh orange wedges 4) Peanut butter cookies

3

A nurse is preparing to insert a nasogastric tube. During insertion, which response indicates that the client is experiencing difficulty? 1. Gagging 2. Discomfort 3. Flushed face 4. Inability to speak

4

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? 1. Obtain the vital signs. 2. Notify the health care provider. 3. Reinsert the protruding organs using aseptic technique. 4. Cover the wound with a sterile towel moistened with normal saline.

4

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? 1) Choking 2) Redness 3) Gagging 4) Cyanosis

4

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? 1) Encircle the drainage on the dressing. 2) Irrigate the suction tube with sterile saline. 3) Clean the drainage port with an alcohol wipe. 4) Compress the container before closing the port.

4

An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube? 1) Once a day 2) Before each feeding 3) At every shift change 4) During the night shift

2

A client experiences elevated triglycerides and cholesterol. The client appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." Which is the nurse's most appropriate response? 1. "Well, yes, that will certainly lower the amount of your blood fats." 2. "That's good, but be sure to compensate by adding more carbohydrates." 3. "You need some fat to supply the necessary fatty acids, so it's mainly just a need to cut down on the amount of fat you consume." 4. "You need some cholesterol in your diet because your body cannot manufacture it, so just avoid excessive amounts."

3

A client has a glycosylated hemoglobin measurement of 6%. What should the nurse conclude about this client when planning a teaching plan based on the results of this laboratory test? 1) Is experiencing a rebound hyperglycemia 2) Needs the insulin changed to a different type 3) Has followed the treatment plan as prescribed 4) Requires further teaching regarding nutritional guidelines

3

A client is admitted with a higher than expected red blood cell (RBC) count. What physiological alteration does the nurse expect will result from this clinical finding? 1. Increased serum pH 2. Decreased hematocrit 3. Increased blood viscosity 4. Decreased immune response

3

The nurse is developing a list of appropriate foods for a client who has been prescribed a low sodium diet. The nurse reviews the list with the client. The nurse evaluates that the teaching is understood when the client states, "It is okay for me to eat: 1) broiled scallops." 2) bologna on rye bread." 3) shredded wheat cereal." 4) canned soup."

3

A client has a large open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing? 1. Use a separate square gauze to cleanse each half of the wound. 2. Apply new Montgomery straps each time the dressing is changed. 3. Hold the wet gauze with the tips of the forceps higher than the wrist. 4. Cleanse the wound with wet sterile gauze from the center of the wound outward.

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