Exam 3: Nutrition and Elimination Prep U
a nurse is admitting an infant who has severe dehydration from acute gastroenteritis. which of the following findings should the nurse expect?
3% weight loss
A nurse administers a continuous tube feeding via an NG tube. How often must the nurse check for residual?
4 to 6 hours
A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 pounds. What would the nurse document as his BMI?
52.4
A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed?
A 43-year-old patient who takes ginko bilboa and an aspirin daily
Which of the following can be used for rehydration therapy for diarrheal disorders?
Oral rehydration solution (ORS)
A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube?
Order radiographic examination of the tube.
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which of the following categories should the nurse understand this client would be placed in?
Overweight
An athlete wants to increase the intake of complex carbohydrates and asks the nurse about potential sources. Which of the following foods is considered a complex carbohydrate?
Pasta
A client presents with complaints of blood in her stools. Upon inspection, the nurse notes streaks of bright red blood visible on the outer surface of formed stool. Which of the following will the nurse further investigate with this client?
Presence or history of hemorrhoids
A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?
Protein
Which of the following is the hallmark of the diagnosis of nephrotic syndrome?
Proteinuria
A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient?
Provide a thirty-minute rest period prior to mealtime.
The nurse is performing a nutritional assessment of an obese patient who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this patient?
Psychological reasons for overeating should be explored, such as eating as a release for boredom.
The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the
RDA level
Which of the following is the most reliable method for verifying the correct placement of a nasogastric tube?
Radiologic confirmation of position
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?
Red
A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?
Remove the tray from the room.
A terminally ill client is receiving morphine around-the-clock for pain control. As part of the client's plan of care focusing on pain management, which nursing diagnosis would the nurse most likely identify?
Risk for constipation related to the effects of an opioid
The nurse is providing teaching for a postoperative client complaining of nausea. Which food would be the most appropriate to recommend?
Saltine crackers
A client with second-degree burns is encouraged to increase the proteins in his or her diet. Which of the following foods are high in protein?
Scrambled eggs with cheese
A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition?
Serum albumin
The nurse is caring for a patient who has dysphagia and is unable to eat independently. While assisting the patient in eating, which of the following actions is most appropriate for the nurse?
Speak to the patient, but reduce the number of distractions while patient is eating.
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Stool specimen for ova and parasites
A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and show signs of respiratory distress. What would be the priority action of the nurse upon this assessment?
Stop advancing the tube and pull it back into the nasal area.
Which of the following is a fat-soluble vitamin?
Vitamin E
A client who has bleeding tendencies has a deficiency in which vitamin?
Vitamin K
The nurse is working with a child with altered genitourinary status. Which intervention would be included in the plan of care with excess fluid volume?
Weigh the child twice a day on the same scale.
a nurse on a medical unit is assessing four clients for urinary retention. which of the following clients have manifestations of urinary retention?
a client who reports urinary frequency
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which factor is of greatest significance in causing an exacerbation of ulcerative colitis?
a demanding and stressful job
a nurse is preparing an in-service for a group of nurses about saw-palmetto. which of the following information should the nurse include?
saw palmetto may cause PSA levels to result in falsely low readings
a nurse is teaching a client who is scheduled for a cystoscopy. which of the following information should the nurse include in the teaching?
you may have pink-tinged urine after this procedure
An elderly client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. She is in a state of
Negative nitrogen balance
The charge nurse is observing a new nurse care for a patient who is receiving a continuous feeding through a nasogastric feeding tube. Which of the following actions by the new nurse would require intervention by the charge nurse?
The new nurse places the patient in the left lateral recumbent position.
A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly?
The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site.
a nurse is teaching a client who has a new diagnosis of urge incontinence. which of the following information should the nurse include in the teaching?
your provider might prescribe anticholinergic medications you should limit fluids in the evening you should restrict your intake of caffeine
a nurse is caring for a client who has bph. which of the following medications should the nurse plan to administer
finasteride
A client has cystitis. The nurse should further assess the client for:
foul-smelling urine.
When the bladder contains 300 mL or more of urine, this is referred to as
functional capacity
a nurse is preparing a presentation about glucosamine to a group of clients. which of the following information should the nurse include in the teaching?
glucosamine may help to increase joint functionality
a nurse is caring for a client who is postoperative following a trans-urethral resection of the prostate. which of the following complications is the priority for the nurse to monitor?
hemorrhage
a charge nurse is observing a newly licensed nurse insert an indwelling urinary catheter for a male client. which of the following actions by the newly license nurse requires intervention by the charge nurse?
lubricates the first 2.5 to 5 cm (1-2 in) of the catheter males should be 15-17.5 cm (6-7 in)
You are slowly advancing a nasogastric tube (NGT) when the patient begins to gasp and is unable to vocalize. Which of the following has likely occurred?
The NGT is in the patient's airway.
a nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. which of the following information should the nurse include?
you should anticipate pain during inflow of the dialysate during the first few weeks of therapy
A nurse is evaluating patients to determine their need for total parenteral nutrition (TPN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. A A patient with irritable bowel syndrome who has intractable diarrhea B A patient with celiac disease not absorbing nutrients from the GI tract C A patient who is underweight and needs short-term nutritional support D A patient who is comatose and needs long-term nutritional support E A patient who has anorexia and refuses to take foods via the oral route F A patient with burns who has not been able to eat adequately for 5 days
A A patient with irritable bowel syndrome who has intractable diarrhea B A patient with celiac disease not absorbing nutrients from the GI tract F A patient with burns who has not been able to eat adequately for 5 days
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?
A full bladder or rectum can impede fetal descent.
The nurse is assessing patients for BMR. Which patient would the nurse suspect would have an increased BMR?
A patient who has a fever
A nurse is teaching a new mother about intussusception. Which signs and symptoms should the nurse include?
Abdominal distension and vomiting
Lactulose (Cephulac) is administered to a patient diagnosed with hepatic encephalopathy to reduce which of the following?
Ammonia
A nurse documents a patient's hemoglobin as 8 g/dL. What nutritional condition does this biochemical data signify?
Anemia
After reviewing the patient's chart, the nurse notes that the patient has been ordered a clear liquid diet. Which meal tray would the patient be allowed to eat?
Bouillon, apple juice, and gelatin
An elderly woman who is incontinent of stool following a cerebrovascular accident will have the following nursing diagnosis
Bowel incontinence related to loss of sphincter control as evidenced by inability to delay the urge to defecate
Which nursing action associated with successful tube feedings follows recommended guidelines?
Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.
A nurse is teaching an adolescent client about nutrition following a hospital admission. Which of the following should the nurse understand about adolescent nutrition?
Childhood nutrition problems may worsen during adolescence.
The nurse should begin the process of removing a patient's nasogastric (NG) tube by doing which of the following?
Confirming the physician's order to remove the tube
The nurse has administered mannitol IV. Which is a priority assessment for the nurse to make after administering this drug?
Monitor urine output.
A nurse is caring for a client who has been ordered a clear liquid diet. Which of the following can be included in the client's diet?
Cranberry juice
Which of the following symptoms are known side effects of antibiotics?
Diarrhea
A nurse is performing postoperative care on a child with a ureteral stent. Which intervention will help manage bladder spasms?
Encourage high fluid intake.
A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake?
Encourage the client to eat in the dining room.
A 56-year-old male patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating his appetite?
Encouraging food from home when possible.
A woman consumes pasta, grains, and other carbohydrates for
Energy
A client is diagnosed with pyelonephritis. Which nursing action is a priority for care now?
Ensure sufficient hydration.
Upon assessment, the nurse determines the patient has a body mass index (BMI) of 45. This finding indicates the patient is which of the following?
Extremely obese
The nurse is scheduling tests for a patient who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?
Fecal occult blood test, barium studies, endoscopic examination
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to what?
Fluid and electrolyte levels
You are inserting a urinary catheter into a 63-year-old male patient and encounter resistance. Which of the following is the most likely cause of the resistance?
The patient has an enlarged prostate.
A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced?
The patient reports fullness and diarrhea after breakfast.
James Roth, a 63-year-old accountant, is a client on the hospital unit where you practice nursing. Mr. Roth has developed urinary incontinence and is beginning bladder training to regain control over his urine elimination. Why is the catheter being clamped and unclamped?
To promote normal bladder function
A physician orders nutritional therapy administered via a central vein for a patient who cannot take foods orally. What is the term for this type of nutrition?
Total parenteral nutrition (TPN)
The nurse has observed that a patient's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the patient's appetite?
Try to ensure that the patient's food is attractive and sufficiently warm.
Which vitamin is found only in animal foods?
Vitamin B12
a nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. the nurse recognizes this finding can be a manifestation of which of the following urinary alterations?
bladder infection
a nurse is caring for a client who has an indwelling urinary catheter. which of the following actions should the nurse take to prevent infection?
check the catheter for kinks or twisting
a nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate. the nurse notes that the client's indwelling catheter has not drained in the past hour. which of the following actions should the nurse take first?
check the tubing for kinks
a nurse is caring for a 3 year child who has had 160 mL of urine output over the past 8 hours. which of the following actions should the nurse take?
continue to monitor the patient
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?
cystitis
a nurse is teaching a client who has benign prostatic hypertrophy and has a new prescription for finasteride. which of the following instructions should the nurse include in the teaching?
decreased libido is an adverse effect of the medication
The nurse recognizes that the older adult is at risk for surgical complications due to:
decreased renal function
a nurse is caring for a client who has BPH. the nurse should expect which of the following findings?
difficulty starting the flow of urine
Which are anticholinergic side effects that may occur with the use of antipsychotic drugs? Select all that apply. diarrhea dry mouth constipation runny nose urinary retention
dry mouth constipation urinary retention
a nurse is implementing a bladder retraining program for a client. which of the following actions should the nurse take
encourage the client to hold her breath when feeling the urge to urinate
Lisa Bentley, a 32-year-old teacher, presents to the gastroenterology office where you work. She is known to have a history of Crohn's disease, and you have met with her several times to discuss the various health concerns that she has related to her diagnosis. When talking with the client, the nurse explains that having a GI disorder doesn't mean her problems are limited to the one area that is diseased but might also involve all of the following except ________.
metabolism
a nurse is assessing a client who has a urine output of 250 mL in a 24 hour period. which of the following descriptive terms should the nurse place in the clients electronic record?
oliguria
Early in pregnancy, frequent urination results mainly from which cause?
pressure on the bladder from the uterus
The nurse is giving discharge instructions to the client with uric acid renal calculi. Which statement by the client indicates the client understands the prescribed diet?
"I should limit my intake of meat and fish."
Which statement by the parent of a child with polycystic kidney disease and stage 2 renal disease indicates the need for more teaching?
"My child will outgrow this disease."
A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which statement made by the mother would be most important?
"She gets constipated often."
When providing client teaching about continuous bladder irrigation following prostate surgery, the nurse should tell the client:
"The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder."
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure?
"You will need to swallow a capsule."
A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to delete per day in order to accomplish this goal?
1000 calories
What is the body mass index (BMI) of a patient who is 1.68 meters tall and weighs 70 kg?
24.8
A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process?
Stroke the underside of the patient's chin to promote swallowing.
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
Sudden, sustained abdominal pain
a nurse is caring for a client who is 2 hr postoperative following a TURP. the client is receiving continuous bladder irrigation. which of the following interventions should the nurse include?
remind the client that he might feel a constant urge to void
a nurse is assessing a client who is experiencing prostatic hypertrophy. which of the following findings associated with urinary retention should the nurse expect?
report of feeling pressure tenderness over the symphysis pubis distended bladder voiding 30mL frequently
A nurse is caring for a female client who is of child-bearing age in the clinic setting. Which of the following vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy?
Folic acid
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
Hepatic encephalopathy
A nurse teaching a student nurse how to remove a nasogastric tube discusses interventions to be performed in unexpected situations. Which of the following statements accurately describes one of these interventions?
If within 2 hours after NG tube removal, the patient's abdomen is showing signs of distention, notify the physician.
Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index (BMI) of 18?
Imbalanced Nutrition: Less Than Body Requirements
A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client?
Imbalanced nutrition, less than body requirements
A 20-year-old woman has announced her intention to implement a zero-fat diet in order to lose weight and maximize her health. What is a potential consequence of completely eliminating fat sources from the woman's diet?
Impaired vitamin absorption
Which of the following is a characteristic of the intrarenal category of acute renal failure?
Increased BUN
The nurse is helping a patient to correctly perform peritoneal dialysis at home. The nurse must educate the patient about the procedure. Which educational information should the nurse provide to the patient?
Keep the dialysis supplies in a clean area, away from children and pets
Mrs. R. has developed an abscess following abdominal surgery and her food intake has been decreasing over the past 2 weeks. Which of the following laboratory findings may suggest the need for nutritional support?
Low serum albumin levels
A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which of the following would the nurse incorporate into the teaching plan as a major reason for the high fiber diet?
Maintenance of normal bowel elimination
A nurse prepares to insert a nasointestinal tube to provide nutrition to a patient. Which of the following is a recommended guideline for this procedure?
Measure tube from the tip of the nose to the ear lobe and from the ear lobe to the xiphoid process.
The nurse is teaching a class about caloric intake. The reason that men and women differ in the amount of calories they require on a daily basis is what?
Men have a larger muscle mass and so require more calories.
A male client's health care provider orders antipsychotic medications for him. He experiences little or no side effects from the medications and is able to function successfully in both his home and work environments. Six weeks later, he is diagnosed with hepatitis B. He begins to experience adverse reactions to his medications. A possible reason for the adverse reactions might be that, in the presence of liver disease, what may happen?
Metabolism may be slowed and drug elimination half-lives prolonged, with resultant accumulation and increased risk of adverse effects.
During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her 6-month-old infant. What does the nurse inform the mother?
New foods should be introduced one at a time for a period of 5 to 7 days.
Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a patient with Cushing's syndrome?
Observe the color of stool
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following facts should the nurse understand about TPN therapy? Select all that apply.
TPN has three primary components: proteins, carbohydrates, and fats. TPN has a high glucose concentration. TPN requires a PICC line or central venous access.
Which of the following is the most common type of prostate surgery?
TURP
What is most important to tell the client who will be taking adrenergic blocking drugs for benign prostatic hypertrophy?
Take the medication at the same time each day.
As a nurse is aspirating the contents during a tube feeding, the nurse finds that the tube is clogged. What would be appropriate nursing interventions in this situation? (Select all that apply.)
Use warm water and gentle pressure to remove clog. If necessary, replace the tube. Ensure that adequate flushing is completed after each feeding.
A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment?
Use warm water and gentle pressure to remove the clog.
A client has a history of long-term alcohol abuse. Which of the following nutrients would need to be required in increased amounts?
Vitamin B
A 62-year-old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition?
Vitamin B malnutrition
A nurse is educating a group of adolescent girls on bone and teeth growth. Which fat-soluble vitamin assists to build bone and teeth?
Vitamin D
A nurse is caring for a client who has had part of her small intestine removed due to cancer. She has also now developed hypertension and has been prescribed a new medication to decrease her blood pressure. While planning the client's care, the nurse should consider a possible alteration in which aspect of pharmacokinetics?
absorption
a nurse is caring for a client who is post-operative following a TURP. the nurse should plan to administer the clients PRN bethanechol when the client reports which of the following manifestations?
an inability to void
a nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate gland. which of the following assessments should the nurse view to be an indication of a postoperative complication?
output of burgundy colored urine
a nurse is assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. the nurse should associate these finding with which of the following types of urinary incontinence?
overflow incontinence
a nurse is caring for a client who has undergone a transurethral prostatectomy. following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?
pale pink
a nurse is reviewing the laboratory data of a client following hemodialysis treatment. the nurse should expect to find a decrease in which of the following laboratory values?
potassium
a nurse is discussing indications for urinary catheterization with a newly licensed nurse. which of the following indications should the nurse include?
relief of urinary retention
Which laboratory test is the best indicator of a patient in need of TPN?
serum albumin
a nurse is monitoring an older adult female client who had myocardial infarction for the development of an acute kidney injury. which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury?
serum creatinine 1.8 mg/dL
a nurse in a long term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. after the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to mange this behavior?
take the client to the bathroom every 2 hours
a nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. the nurse should recognize that these findings are associated with which of the following
urinary tract infection
a nurse is caring for a client who has impaired renal function. for which of the following findings should the nurse notify the provider
urine output of 175 mL in the last 8 hr
a nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. which of the following instructions should the nurse include?
use soap and water to wash the catheter after each use
a nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate and has continuous bladder irrigation in place. which of the following actions should the nurse take?
use sterile technique when preparing the irrigation solution ensure the drainage tubing is patent and without obstruction notify the surgeon if the urine is bright red in appearance or has large clots
Which finding would alert the nurse to suspect that a client has a yeast infection?
vulvar burning and itching
a nurse is providing discharge instructions to a female client who has neuropathy and a new prescription for gabapentin. which of the following statements should the nurse include in the teaching?
you may experience drowsiness while taking this medication
