Week 4 Mock Question

A patient is using laxatives 3 times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? A. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. B. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. C. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations. D. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

A Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed.

A nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include? A. Have values for protein, vitamins, and minerals. B. Are based on percentages of fat, cholesterol, and fiber. C. Have replaced recommended daily allowances (RDAs). D. Are used to develop diets for chronic illnesses requiring 1800 cal/day.

A The RDIs are the first set, comprising protein, vitamins, and minerals based on the RDA. The daily reference values (DRVs) make up the second set and consist of nutrients such as total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium, and potassium. Combined, both sets make up the daily values used on food labels. Daily values did not replace RDAs but provided a separate, more understandable format for the public. Daily values are based on percentages of a diet consisting of 2000 kcal/day for adults and children 4 years or older.

The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? A. Check the skin around the tube insertion site. B. Weigh the client every shift with the same scale. C. Draw blood to assess albumin every shift. D. Irrigate the tube at least once a day.

A The most important assessment would be to observe the skin around the tube for irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage and moisture which can lead to excoriation or other type of skin breakdown. For a client who is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive indicator of over nutritional health. The G-tube is not routinely irrigated.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says" ―I didn't know it would be this hard to live like this." What approach by the nurse is best? A. Assess the client's coping and support systems. B. Inform the client that things will get easier. C. Re-educate the client on needed dietary changes. D. Tell the client that lifestyle changes are always hard.

A The nurse would assess this patient's coping styles and support systems to best provideholistic care. The other options do not address the patient's distress.

The nurse is planning care for a group of stable patients. Which task will the nurse assign to the nursing assistive personnel? A. Measuring capillary blood glucose level B. Measuring nasoenteric tube for insertion C. Measuring pH in gastrointestinal aspirate D. Measuring the patient's risk for aspiration

A The skill of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to nursing assistive personnel when the patient's condition is stable. The other skills cannot be delegated. A nurse must measure a nasoenteric tube for insertion, pH in gastrointestinal aspirate, and patient's risk for aspiration

The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient's skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide? A. Drink more water to prevent further dehydration. B. Drink more calorie-dense fluids to increase caloric intake. C. Drink more milk and dairy products to decrease the risk of osteoporosis. D. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.

A Thirst sensation diminishes, leading to inadequate fluid intake or dehydration; the patient should be encouraged to drink more water/fluids. Symptoms of dehydration in older adults include confusion, weakness, hot dry skin, furrowed tongue, and high urinary sodium. Milk continues to be an important food for older woman and men, who need adequate calcium to protect against osteoporosis; the patient's problem is dehydration, not osteoporosis. Caution older adults to avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs. The patient needs fluids, not calories; drinking calorie-dense fluids is unnecessary.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service? A. African-American churches B. Asian-American groceries C. High school sports camps D. Women's health clinics

A African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement? A. X-ray B. pH testing C. Auscultation D. Aspiration of contents

A At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. Aspiration of contents and pH testing are not infallible. The nurse would need a more precise indicator to help differentiate the source of tube feeding aspirate. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach.

The nurse is describing the ChooseMyPlate program to a patient. Which statement from the patient indicates successful learning? A. "I can use this to make healthy lifestyle food choices." B. "I can use this to count specific calories of food." C. "I can use this for my baby girl." D. "I can use this when I am sick."

A ChooseMyPlate serves as a basic guide for making food choices for a healthy lifestyle. The ChooseMyPlate program was developed by the U.S. Department of Agriculture to replace the MyFoodPyramid program. It helps balance calories but does not provide specific calories of food. These guidelines are for Americans over the age of 2 years. These guidelines are provided for health, not sickness.

The patient has just started on enteral feedings, and is now reporting abdominal cramping. Which action will the nurse take next? A. Slow the rate of tube feeding. B. Instill cold formula to "numb" the stomach. C. Change the tube feeding to a high-fat formula. D. Consult with the health care provider about prokinetic medication.

A One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the rate of delivery may increase tolerance. Another possible cause of abdominal cramping is the use of cold formula. The nurse should warm the formula to room temperature. High-fat formulas are also a cause of abdominal cramping. Consult with the health care provider regarding prokinetic medication for increasing gastric motility for delayed gastric emptying.

The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate? A. Ask the client if the weight loss was intentional. B. Determine if there are food allergies or intolerances. C. Perform a comprehensive nutritional assessment. D. Perform a rapid bedside blood glucose test.

A Rational: This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted

The patient is on parenteral nutrition is lethargic while reporting thirst and headache and has had increased urination. Which problem does the nurse prepare to address? a. Hyperglycemia b. Hypoglycemia c. Hypercapnia d. Hypocapnia

A Signs and symptoms of hyperglycemia are thirst, headache, lethargy, and increased urination. Hypocapnia is not associated with parenteral nutrition. Hypercapnia increases oxygen consumption and increases CO2 levels. Ventilator-dependent patients are at greatest risk for this. Hypoglycemia is characterized by diaphoresis, shakiness, confusion, and loss of consciousness.

The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan? A. Provide small, frequent nutrient-dense meals for maximizing kilocalories. B. Prepare hot meals because they are more easily tolerated by the patient. C. Avoid salty foods and limit liquids to preserve electrolytes. D. Encourage intake of fatty foods to increase caloric intake.

A Small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods are easier to tolerate. Restorative care of malnutrition resulting from AIDS focuses on maximizing kilocalories and nutrients. Patients benefit from eating cold foods and drier or saltier foods with fluid in between.

When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan? A. Increasing carbohydrates to 55% to 60% of total intake B. Providing vitamin and mineral supplements C. Decreasing protein intake to 0.75 g/kg/day D. Limiting water before and after exercise

A Sports and regular moderate to intense exercise necessitate dietary modification to meet increased energy needs for adolescents. Carbohydrates, both simple and complex, are the main source of energy, providing 55% to 60% of total daily kilocalories. Protein needs increase to 1 to 1.5 g/kg/day. Fat needs do not increase. Adequate hydration is very important. Adolescents need to ingest water before and after exercise to prevent dehydration, especially in hot, humid environments. Vitamin and mineral supplements are not required, but intake of iron-rich foods is required to prevent anemia.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? A. Assess the 24-hour intake and output. B. Assess the client's oral cavity. C. Prepare to hang a normal saline bolus. D. Increase the infusion rate of the TPN.

A This client has clinical indicators of dehydration, so the nurse calculates the patient's 24-hour intake, output, and fluid balance. This information is then reported to the health care provider. The client's oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client's dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate would make the problem worse, and is not done as an independent action for clients receiving

A nurse is working with a client who takes clopidogrel. The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? A. Ask if the client eats grapefruit. B. Assess the client for dehydration. C. Facilitate admission to the hospital. D. Obtain a random urinalysis.

A There is a drug-food interaction between clopidogrel and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse would assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) A. Alopecia B. Stomatitis C. Muscle wasting D. Peripheral edema E. Anemia F. Dry, scaly skin

A, B, C, D, E, F All of these body changes occur due to nutrient deficiencies associated with low protein, zinc, Vitamin A, and complex B vitamins.

When working with older adults to promote good nutrition, what action(s) by the nurse is(are) most appropriate? (Select all that apply.) A. Allow uninterrupted time for eating. B. Assess dentures (if worn) for appropriate fit. C. Ensure that the client has glasses on or contacts in when eating. D. Provide salty or highly spicy foods that the client can taste. E. Serve high-calorie, high-protein snacks one to two times a day.

A, B, C, E Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses or contacts, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty or spicy snacks are not recommended because all adults should limit sodium in their diets and spicy foods may not be tolerated.

A nurse is teaching a health class about the nutritional requirements throughout the life span. Which information should the nurse include in the teaching session? (Select all that apply.) A. Infants triple weight at 1 year. B. Toddlers become picky eaters. C. School-age children need to avoid hot dogs and grapes. D. Breastfeeding women need an additional 750 kcal/day. E. Older adults have altered food flavor from a decrease in taste cells.

A, B, E An infant usually doubles birth weight at 4 to 5 months and triples it at 1 year. Toddlers exhibit strong food preferences and become picky eaters. Older adults often experience a decrease in taste cells that alters food flavor and may decrease intake. Toddlers need to avoid hot dogs and grapes, not school-age children. The lactating woman needs 500 kcal/day above the usual allowance because the production of milk increases energy requirements.

The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient which teaching points? (Select all that apply.) A. Increase physical activity. B. Keep total fat intake to 10% or less. C. Maintain body weight in a healthy range. D. Choose and prepare foods with little salt. E. Increase intake of meat and other high-protein foods.

A, C, D Recommendations include maintaining body weight in a healthy range; increasing physical activity and decreasing sedentary activities; increasing intake of fruits, vegetables, whole grain products, and fat-free or low-fat milk; eating moderate amount of lean meats, poultry, and eggs; keeping fat intake between 20% and 35% of total calories, with most fats coming from polyunsaturated or monounsaturated fatty acids (most meats contain saturated fatty acids); and choosing prepared foods with little salt while at the same time eating potassium-rich foods.

The nurse will irrigate a patient's nasogastric (NG) tube. Which action should the nurse take? A. Instill solution into pigtail slowly. B. Check placement after instillation of solution. C. Immediately aspirate after instilling fluid. D. Prepare 60 mL of tap water into Asepto syringe.

C After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue "pigtail" air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of irrigating solution into lungs. Draw up 30 mL of normal saline into Asepto syringe to minimize loss of electrolytes from stomach fluids.

A client just returned to the surgical unit after an open traditional gastric bypass. What action by the nurse is the priority? A. Assess the patient's pain. B. Check the surgical incision. C. Ensure an adequate airway. D. Program the morphine pump.

C All actions are appropriate care measures for this patient; however, airway is always the priority. Bariatric patients tend to have short, thick necks that complicate airway management.

The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? A. Intermittent diarrhea B. Cholecystitis C. Aspiration pneumonia D. Peptic ulcer disease

C Aspiration pneumonia is one of the most common complications in older adults who have enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased. Intermittent diarrhea may also occur, but that is not potentially life threatening if the client does not become dehydrated.

Before giving the patient an intermittent gastric tube feeding, what should the nurse do? A. Make sure that the tube is secured to the gown with a safety pin. B. Inject air into the stomach via the tube and auscultate. C. Have the tube feeding at room temperature. D. Check to make sure pH is at least 5.

C Be sure that the formula is at room temperature. Cold formula causes gastric cramping and discomfort because the mouth and the esophagus do not warm the liquid. Do not use safety pins. Safety pins can become unfastened and may cause harm to the patient. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach. Gastric fluid of patient who has fasted for at least 4 hours usually has a pH of 1 to 4, especially when the patient is not receiving gastric-acid inhibitor.

In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother? A. Calcium intake is especially important in the first trimester. B. Protein intake needs to decrease to preserve kidney function. C. Folic acid is needed to help prevent birth defects and anemia. D. Extra vitamins and minerals should be taken as much as possible.

C Folic acid intake is particularly important for DNA synthesis and growth of red blood cells. Inadequate intake may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. Protein intake throughout pregnancy needs to increase to 60 g daily. Calcium intake is especially critical in the third trimester, when fetal bones mineralize. Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes; however, pregnant women should not take additional supplements beyond prescribed amounts

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? A. Broccoli and cheese soup with potato bread B. Turkey and mashed potatoes with brown gravy C. Grape and walnut chicken salad sandwich on whole wheat bread D. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing

C Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain as much fiber as whole wheat bread. A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.

The patient has been diagnosed with Helicobacter pylori. The nurse should encourage which action initially? A. Avoidance of wheat and oats. B. Milkshakes as a nutritious snack. D. Completion of antibiotic therapy. C. Nonsteroidal antiinflammatory drugs.

C Helicobacter pylori, a bacterium that causes up to 85% of peptic ulcers, is confirmed by laboratory tests or a biopsy during endoscopy. Antibiotics treat and control the bacterial infection. Avoidance of wheat and oats are required for patients with celiac disease who must follow a gluten-free diet. Encourage patients to avoid foods that increase stomach acidity and pain such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and certain seasonings (hot chi

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea? A. Antibiotic therapy B. Clostridium difficile C. Formula intolerance D. Bacterial contamination

C Hyperosmolar formulas can cause diarrhea or formula intolerance. If that is the case, the solution is to lower the rate, dilute the formula, or change to an isotonic formula. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allowing for C. difficile toxin buildup. However, this takes time (more than 2 hours), and no indication suggests that this patient is on antibiotics. Bacterial contamination of the feeding usually occurs when feedings are left hanging for longer than 8 hours.

In general, when a patient's energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? A. Weight increases. B. Weight decreases. C. Weight does not change. D. Weight fluctuates daily.

C In general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change. When kilocalories ingested exceed a person's energy demands, the individual gains weight. If kilocalories ingested fail to meet a person's energy requirement, the individual loses weight. Fluid, not kilocalories, causes daily weight fluctuations.

Which assessment finding is consistent with the diagnosis of malnutrition? A. Moist lips B. Pink conjunctivae C. Spoon-shaped nails D. Not easily plucked hair

C Spoon-shaped nails, koilonychia, is an indication of poor nutrition. All the others are normal findings. Lips should be moist, conjunctivae should be pink, and hair should not be easily plucked.

The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do? A. Increase the rate to get the volume caught up before discontinuing. B. Stop the infusion as ordered. C. Taper infusion gradually. D. Hang 5% dextrose.

C Sudden discontinuation of PN can cause hypoglycemia. PN must be tapered off. Usually, 10% dextrose is infused when PN solution is suddenly discontinued. Too rapid administration of hypertonic dextrose (PN) can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up

A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time? A. Listen to the client's bowel sounds. B. Call the Rapid Response Team. C. Take the client's vital signs. D. Contact the primary health care provider.

C The client may be experiencing either bleeding or anastomosis leak(s). Clients having these complications have severe abdominal, back, or shoulder pain, tachycardia, and hypotension.

A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? A. Administer an antiemetic. B. Check the patient's gastric residual. C. Hold the feeding until the vomiting subsides. D. Reduce the rate of the tube feeding by half.

C The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary health care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)? A. Performing the first postoperative pouch change B. Maintaining a nasogastric tube C. Administering an enema D. Digitally removing stool

C The skill of administering an enema can be delegated to an AP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an AP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel.

A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1. Elevate head of bed to at least 30 degrees. 2. Check for gastric residual volume. 3. Flush tubing with 30 mL of water. 4. Verify tube placement. 5. Initiate feeding. A. 4, 2, 1, 5, 3 B. 2, 4, 1, 3, 5 C. 1, 4, 2, 3, 5 D. 2, 1, 4, 5, 3

C The steps for an enteral feeding are as follows: place patient in high-Fowler's position or elevate head of bed to at least 30 (preferably 45) degrees, verify tube placement, check for gastric residual volume, flush tubing with 30 mL of water, and initiate feeding.

Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube? Instill Xylocaine into the nares once a shift. Tape tube securely with light pressure on nare. Lubricate the nares with water-soluble lubricant. Apply a small ice bag to the nose for 5 minutes every 4 hours.

C The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose.

A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority? A. Reduce dependent nitrogen balance. B. Maintain negative nitrogen balance. C. Promote positive nitrogen balance. D. Facilitate neutral nitrogen balance.

C When intake of nitrogen is greater than output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. Negative nitrogen balance occurs when the body loses more nitrogen than the body gains. Neutral nitrogen balance occurs when gain equals loss and is not optimal for tissue healing. There is no such term as dependent nitrogen balance.

The patient diagnosed with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful? A. Maintain a prescribed carbohydrate intake. B. Eat fish at least 5 times/week. C. Limit cholesterol to less than 300 mg/daily. D. Avoid high-fiber foods

C American Heart Association guidelines recommend limiting cholesterol to less than 300 mg/day. Diet therapy includes eating fish at least 2 times per week and eating whole grain high-fiber foods. Maintaining a prescribed carbohydrate intake is necessary for diabetes mellitus.

A nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the nurse include in the directions to the AP? (Select all that apply.) A. Allow 30 minutes for eating so food doesn't get spoiled. B. Assess the patient's mouth while providing premeal oral care. C. Ensure that warm and cold items stay at appropriate temperatures. D. Remove bedpans, soiled linens, and other unpleasant items. E. Sit with the client, making the atmosphere more relaxed.

C, D, E The AP should make sure that food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The AP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse.

The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? A. Normal weight B. Underweight C. Overweight D. Obese

D BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI from 18.5 to 24.9 is normal. BMI under 18.5 is underweight.

In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide? A. Supplement breast milk with corn syrup. B. Give cow's milk during the first year of life. C. Add honey to infant formulas for increased energy. D. Provide breast milk or formula for the first 4 to 6 months.

D Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. Infants should not have regular cow's milk during the first year of life. It is too concentrated for an infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Furthermore, children under 1 year of age should never ingest honey and corn syrup products because they are potential sources of the botulism toxin, which increases the risk of infant death

The patient who has been diagnosed with cardiovascular disease and placed on a low-fat diet, asks the nurse, "How much fat should I have? I guess the less fat, the better." Which information will the nurse include in the teaching session? A. Cholesterol intake needs to be less than 300 mg/day. B. Fats have no significance in health and the incidence of disease. C. All fats come from external sources, so this can be easily controlled. D. Deficiencies occur when fat intake falls below 10% of daily nutrition.

D Deficiency occurs when fat intake falls below 10% of daily nutrition. While keeping cholesterol below 300 mg is correct according to the American Heart Association, it does not answer the patient's question about fat. Various types of fatty acids have significance for health and for the incidence of disease and are referred to in dietary guidelines. Linoleic acid and arachidonic acid are important for metabolic processes but are manufactured by the body when linoleic acid is available from the diet.

The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? A. Run lipids for no longer than 24 hours. B. Take down a running bag of TPN after 36 hours. C. Clean injection port with alcohol 5 seconds before and after use. D. Wear a sterile mask when changing the central venous catheter dressing.

D During central venous catheter dressing changes, always use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection. To avoid infection, change the TPN infusion tubing every 24 hours, and do not hang a single container of PN for longer than 24 hours or lipids longer than 12 hours.

A nurse is asked how many kcal/g are provided by fats. How should the nurse answer? a. 3 b. 4 c. 6 d. 9

D Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Carbohydrates and protein provide 4 kcal/g.

A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by the nurse is the priority? A. Auscultate lung sounds after each feeding. B. Weigh the client daily on the same scale. C. Check tube placement every 8 hours. D. Check tube placement before each feeding.

D For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met, but it is not the priority.

A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene? A. Custard B. Frozen yogurt C. Pureed vegetables D. Mashed potatoes and gravy

D Mashed potatoes and gravy are on a dysphagia, mechanical soft, soft and regular diet but are not components of a full liquid diet. The nurse will need to provide teaching on what is allowed on the diet. Custard, frozen yogurt, and pureed vegetables are all on a full liquid diet.

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? A. From the tip of the nose to the earlobe B. From the tip of the earlobe to the xiphoid process C. From the tip of the earlobe to the nose to the xiphoid process D. From the tip of the nose to the earlobe to the xiphoid process

D Measure distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. This approximates the distance from the nose to the stomach in 98% of patients. For duodenal or jejunal placement, an additional 20 to 30 cm is required.

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? A. Polyunsaturated fats should be less than 7% of the total calories. B. Trans fat should be less than 7% of the total calories. C. Unsaturated fats are found mostly in animal sources. D. Saturated fats are found mostly in animal sources.

D Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Diet recommendations include limiting saturated and trans fat to less than 10%.

Which patient diagnosis increases the risk for developing neurogenic dysphagia? A. Benign peptic stricture B. Muscular dystrophy C. Myasthenia gravis D. Stroke

D Stroke is the only cause of dysphagia in this list that is considered neurogenic. Myasthenia gravis and muscular dystrophy are considered myogenic in origin, whereas benign peptic stricture is considered obstructive.

The nurse is teaching a health class about the ChooseMyPlate program. Which guidelines will the nurse include in the teaching session? A. Balancing sodium and potassium B. Decreasing water consumption C. Increasing portion size D. Balancing calories

D The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars. It does not balance sodium and potassium.

A nurse is teaching a patient about proteins that must be obtained through the diet since they cannot be synthesized in the body. Which term used by the patient indicates teaching is successful? A. Amino acids B. Triglycerides C. Dispensable amino acids D. Indispensable amino acids

D The body does not synthesize indispensable amino acids, so these need to be provided in the diet. The simplest form of protein is the amino acid. The body synthesizes dispensable amino acids. Triglycerides are made up of three fatty acids attached to a glycerol.

The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? A. Assess for carbon dioxide using capnometry. B. Perform pH testing of gastric fluid. C. Auscultate over the epigastric area. D. Request an x-ray before starting the feeding.

D The most reliable assessment to determine correct feeding tube placement in to have an x-ray to visualize where the tip of the tube is located.

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? A. Instill nonliquid medications without diluting. B. Irrigate the tube with 60 mL of water after all medications are given. C. Mix all medications together to decrease the number of administrations. D. Check with the pharmacy for availability of the liquid forms of medications.

D Use liquid medications when available to prevent tube occlusion. Irrigate with 30 mL of water before and after each medication per tube. Completely dissolve crushed medications in liquid if liquid medication is not available. Read pharmacological information on compatibility of drugs and formula before mixing medications.

The nurse is assessing a patient for nutritional status. Which action will the nurse take? A. Forego the assessment in the presence of chronic disease. B. Use the Mini Nutritional Assessment for pediatric patients. C. Choose a single objective tool that fits the patient's condition. D. Combine multiple objective measures with subjective measures.

D Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems. Using a single objective measure is ineffective in predicting risk of nutritional problems. Chronic disease and increased metabolic requirements are risk factors for the development of nutritional problems; these patients may be in critical need of this assessment. The Mini Nutritional Assessment is used for screening older adults in home care programs, nursing homes, and hospitals.

When assessing patient with nutritional needs, which patients will require follow-up from the nurse? (Select all that apply.) A. A patient with infection taking tetracycline with milk B. A patient with irritable bowel syndrome increasing fiber C. A patient with diverticulitis following a high-fiber diet daily D. A patient with an enteral feeding and 500 mL of gastric residual E. A patient with dysphagia being referred to a speech-language pathologist

A, C, D The nurse should follow up with the tetracycline, diverticulitis, and enteral feeding. Tetracycline has decreased drug absorption with milk and antacids and has decreased nutrient absorption of calcium from binding. Nutritional treatment for diverticulitis includes a moderate- or low-residue diet until the infection subsides. Afterward, prescribing a high-fiber diet for chronic diverticula problems ensues. A patient with a gastric residual volume of 500 mL needs to have the feeding withheld and reassessed for tolerance to feedings. All the rest are normal and expected and do not require follow-up. Patients manage irritable bowel syndrome by increasing fiber, reducing fat, avoiding large meals, and avoiding lactose or sorbitol-containing foods for susceptible individuals. Initiate consultation with a speech-language pathologist for swallowing exercises and techniques to improve swallowing and reduce risk of aspiration for a patient with dysphagia.

The nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to occur? (Select all that apply.) A. Cultural food preferences B. Family bringing snacks C. Increased need for nutrition D. Need for NPO status E. Staff shortages

A, C, D, E Many factors increase the hospitalized client's risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill patients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume that the snacks are leading to undernutrition.

To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select all that apply.) A. Allows fasting on Yom Kippur for a Jewish patient. B. Allows caffeine drinks for a Mormon patient. C. Serves no ham products to a Muslim patient. D. Serves kosher foods to a Christian patient. E. Serves no meat or fish to a Hindu patient.

A, C, E The Jewish religion fasts 24 hours on Yom Kippur and must adhere to kosher food preparation methods. Hinduism requires no meats or fish. Muslims do not eat pork. Mormons do not drink caffeinated or alcoholic drinks.

A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? A. Client with an albumin of 3.5 g/dL B. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) C. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) D. Client with a prealbumin of 28 mg/dL

B A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

The nurse is concerned about pulmonary aspiration when providing care to the patient with an intermittent tube feeding. Which action is the priority? A. Observe the color of gastric contents. B. Verify tube placement before feeding. C. Add blue food coloring to the enteral formula. D. Run the formula over 12 hours to decrease overload.

B A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs to first verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward. While observing the color of gastric contents is a component, it is not the priority component; pH is the primary component. The addition of blue food coloring to enteral formula to assist with detection of aspirate is no longer used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium for bacterial growth after that length of time.

The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain? A. 10-mL Luer-Lok syringe B. Asepto syringe C. Sterile gloves D. Double gloves

B ENFit syringe is needed for testing of gastric aspirate for pH; these syringes are better than a Luer-Lok syringe. Clean gloves are needed, not sterile or double.

A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for the nurse to provide? A. "―Increase the fiber and water in your diet to prevent diarrhea." B. "―Report any suicidal thoughts to your primary health care provider" C. "―Report dry mouth and decreased sweating." D. "―Do not take antibiotics or nay other anti-infective drugs."

B Lorcaserin can cause suicidal thoughts which needs to be reported to the client's primary health care provider. This drug can also cause dry mouth but not decreased sweating. Loose stools are most common with orlistat. Increasing fiber and water would help to prevent constipation, not diarrhea.

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? A. Answering questions the client has about surgery B. Beginning venous thromboembolism prophylaxis C. Informing the client that he or she will be out of bed tomorrow D. Teaching the client about needed dietary changes

B Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbingleg pain on the affected side, rated as 7/10. What action by the nurse is most important? A. Administer pain medication as ordered. B. Assess distal pulses and skin color. C. Document the findings in the client's chart. D. Notify the surgeon immediately.

B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse would assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines that the client's perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding? A. Nasogastric tube B. Jejunostomy tube C. Nasointestinal tube D. Percutaneous endoscopic gastrostomy (PEG) tube

B Patients with gastroparesis or esophageal reflux or with a history of aspiration pneumonia may require placement of tubes beyond the stomach into the intestine. The jejunostomy tube is the only tube in the list that is beyond the stomach and is not contraindicated by facial trauma. The nasogastric tube and the PEG tube are placed in the stomach, and placement could lead to aspiration. The nasointestinal tube and the nasogastric tube may be contraindicated by facial trauma and the broken nose

A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What form of energy is the nurse discussing? A. Resting energy expenditure (REE) B. Basal metabolic rate (BMR) C. Nutrient density D. Nutrients

B The basal metabolic rate (BMR) is the energy needed at rest to maintain life-sustaining activities for a specific period of time. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High-nutrient density foods provide a large number of nutrients in relation to kilocalories.

he nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet? A. A 4-ounce steak, French fries, iceberg lettuce B. Baked chicken breast, broccoli, tomatoes C. Fried catfish, cornbread, peas D. Spaghetti with meat sauce, garlic bread

B The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

A nurse is caring for a group of patients. Which patient will the nurse see first? A. Patient receiving total parenteral nutrition of 2-in-1 for 50 hours B. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours C. Patient receiving continuous enteral feeding with same feeding bag for 12 hours D. Patient receiving continuous enteral feeding with same tubing for 24 hours

B The nurse should see the patient with total parenteral nutrition that has the same tubing for 26 hours. To prevent infection, change the TPN infusion tubing every 24 hours. Change the administration system every 72 hours when infusing a 2-in-1 solution and every 24 hours for a 3-in-1 solution. Change bag and use a new administration set every 24 hours for a continuous enteral feeding. While the patient with the continuous enteral feeding has the same tubing for 24 hours, it has not extended the time like the total parenteral nutrition has.

A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested? A. Improperly home-canned food B. Undercooked ground beef C. Soft cheese D. Custard

B Undercooked ground beef is the usual food source for E. coli. Botulism is associated with improperly home-canned foods. Soft cheese is the usual food source for listeriosis. Custards are associated with salmonellosis and Staphylococcus.

A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? A. Position in semi-Fowler's. B. Flex head with chin down. C. Place food on left side. D. Offer fruit juice.

B Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the patient has unilateral weakness, teach him or her and the caregiver to place food in the stronger side of the mouth. Provide a 30-minute rest period before eating and position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. Thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated

In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient? A. Insulin is the only consideration that must be taken into account. B. Saturated fat should be limited to less than 7% of total calories. C. Nonnutritive sweeteners can be used without restriction. D. Cholesterol intake should be greater than 200 mg/day.

B The diabetic patient should limit saturated fat to less than 7% of total calories and cholesterol intake to less than 200 mg/day. Type 1 diabetes requires both insulin and dietary restrictions for optimal control. Nonnutritive sweeteners can be eaten as long as the recommended daily intake levels are followed.

A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.) A. Attempt to dissolve the clog by instilling a cola product. B. Determine if any of the medications come in liquid form. C. Flush the tube before and after administering medications. D. Mix all medications in the formula and use a feeding pump. E. Try to flush the tube with 30 mL of water and gentle pressure.

B, C, E If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula.

The nurse is providing nutrition education to a Korean patient using the five food groups. In doing so, what should be the focus of the teaching? A. Discouraging the patient's ethnic food choices B. Changing the patient's diet to a more conventional American diet C. Including racial and ethnic practices with food preferences of the patient D. Comparing the patient's ethnic preferences with American dietary choices

C

The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2.What does this value indicate to the nurse? A. The client has a healthy weight. B. The client is underweight. C. The client is obese. D. The client is overweight.

C A BMI of over 30 indicates that the client is obese.