NUR 204 ATI Questions Exam 3

A nurse is teaching a client with heart disease about a low cholesterol diet. Which of the following client statements indicates the teaching was effective?

I should remove the skin from poultry before eating it

a nurse is caring for a client who has chronic kidney dz. The kidneys regulate body fluids as well as assisting with which of the following fxns?

regulation of acid-base balance

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

"Bear Down."

A nurse is planning an in service training session about nutrition. Which of the following statements should the nurse include in the teaching?

"Fats provide energy." Fat serves a stored energy source for the body, providing 9cal/g of energy.

A nurse is caring for a client who is post-op following a vaginal hysterectomy and asks for a drink. Her post op diet rx states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make?

"I am going to listen to your abdomen."

A nurse is completing dietary teaching with a client who has HF and is prescribed a 2g sodium diet. Which of the following statements by the client indicates an understanding of the teaching?

"I can have yogurt as a dessert."

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following client is at risk of iron deficiency?

A client who is a vegetarian A client who is pregnant A toddler who is overweight

A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care?

Avoid salty foods

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching?

Black Beans Whole grain bread

A nurse in a provider's office is assessing a client who has HF. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?

Bounding pulse

a nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis

A nurse is preforming a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

Perform a blanch test

A nurse is preparing to administer a cleaning enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side.

The nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing intervention is the highest priority when the nurse suspects aspiration of the feeding?

Stop the feeding.

A nurse is providing teaching for a client who has a rx for a low sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching?

"I can snack on fresh fruit."

A nurse is providing teaching about food choices to a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

"I should replace white bread with whole grain bread"

A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat more cold foods at meals rather than hot foods."

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

"The dietician will help you choose foods you are used to that also meet your health needs."

A nurse is providing teaching to a client who has type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following response should the nurse provide?

"You don't have to give up pasta; just adjust the amount you eat."

A nurse is providing a teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include?

"include 2.5 cups of veggies in your daily diet."

A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding?

1,000

A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5kg?

10 weeks

A nurse is presenting an in service training session about nutrition. How many of the amino acids must be obtained from dietary intake?

9

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has HF and is receiving 100% oxygen via partial rebreather mask

A nurse is caring for a client who is well hydrated and has no visible evidence of nutritional deficiencies. A lab result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

Albumin

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take?

Apply light pressure to the scanner head once it is in position

A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?

Ask the client to identify the types of foods she prefers.

A nurse is assisting a client who has dysphagia with eating meals. Which of the following actions should the nurse take?

Ask the client to think of a food that produced salivation

A home health nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care?

Baked Chicken Well-cooked meats including baked chicken, do not pose a threat to clients who have neutropenia and may be included in the client's dietary plan. For optimal safety, poultry should be cooked an internal temp of 74 degrees C or 165 degrees F.

A nurse is caring for a group of clients on a medical surgical unit. Which of the following disorders should the nurse identify as increasing the client's metabolic needs?

COPD Cancer Parkinson's Disease Major burns

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy?

Carbohydrates The body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose level every 4 hr The nurse should check the client's capillary blood glucose level every 4 hours or according to facility policy due to the client's risk of hyperglycemia while receiving TPN. The dextrose concentration in TPN increases the risk of this complication.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take?

Check the client's perineum

A nurse is teaching about a low cholesterol diet to a client who had a myocardial infarction.

Chicken breast and corn on the cob

A nurse is collecting urine specimen for culture and sensitivity for a client who has a UTI. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is providing teachings about proper care to a client who has a new colostomy. Which of the following pieces of info should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water.

A nurse is caring for a client who has diverticulitis and a new rx for a low fiber diet. Which of the following food items should the nurse remove from the client's meal tray?

Coleslaw

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

A nurse is reviewing the lab findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect?

Decreased Albumin. A decrease in the albumin level can be an indication of long term protein depleting. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function.

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits

A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile?

Digesting Fats Bile is a product of the liver and aids in the digestion of fats.

A nurse is conducting dietary teaching with a client who has a hx of renal calculi. Which of the following instructions should the nurse include in the teaching?

Drink 3.8L of water throughout the day

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calories malnourishment?

Dry brittle hair, edema, poor wound healing

A nurse is updating the plan of care for a client who has dumping syndrome. Which of the following instructions should the nurse include?

Eat a source of protein with each meal

A nurse is providing teaching to a client who has constipation. Which of the following instructions should the nurse include?

Eat yogurt with live cultures. Yogurt with live bacterial cultures provides dietary probiotics that help maintain and promote bowel functions.

A nurse is caring for a client who has a protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs

A nurse is planning care for a client who is postoperative following a gastrectomy. Which of the following strategies should the nurse include to help prevent dumping syndrome?

Eliminate simple sugars and sugar alcohols from the client's diet.

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast. Grilled chicken, a baked potato, and a glass of milk for lunch; and an apple, cheddar cheese for snack; 2 servings of chicken, 2 cups of steamed broccoli and a glass of milk for dinner. The client's diet is deficient in which of the following groups?

Grains

A nurse in an emergency dept is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

Grasp the skin fold on the chest under the clavicle, release it and note whether it springs back

A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend?

Grilled Chicken

A nurse in a provider's office is assessing a client. The nurse determines the client's body mass index is 21.2. This finding is classified as which of the following?

Healthy weight

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is reviewing the dietary choices of a client who has chronic pancreatitis. Which of the following food items should the nurse suggest removing from the client's menu for the following day?

Ice Cream Clients who have chronic pancreatitis should limit their fat intake to no more than 30% to 40% of total calories.

A nurse is caring for a client who is 48 hr post-op following a small bowel resection. The client reports gas pain in the preumbilical area. The nurse should plan care based on which of the following factors contributing to this post-op complication?

Impaired peristalsis of the intestine

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Increased HR

A nurse is administering a cleansing enema to a client who is scheduled for diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1 in)

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?

Instruct the client to tuck their chin when swallowing. Tucking the chin when swallowing allows food to pass down the esophagus more easily.

A nurse is planning an in service training session regarding nutrition. Which of the following minerals should the nurse identify as involved in oxygen transportation?

Iron

A nurse is providing nutritional counseling for a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet?

Iron

A nurse is talking with the parent of a preschool-aged child who tells the nurse. "My child has suddenly become uninterested in certain foods." Which of the following statements should the nurse make?

Keep a diary of the foods your child eats each day. Keeping a food diary can help the parent realize that the child may be eating better than expected.

A nurse is presenting an in service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrates found in milk?

Lactose

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?

Lentils

A provider tells a client at 12 weeks gestation who practices Hinduism that she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?

Let's discuss other foods that are also high in protein that you could substitute for meat

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

Limit drinking liquids with food

A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching?

Maintain a supine position after meals.

A nurse is planning care for a client who is receiving chemo and has a protein deficiency. Which of the following interventions should the nurse include in the plan of care?

Mix powdered skim milk in liquid milk Add a slice of cheese to veggies Mix yogurt into fresh fruit

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take?

Obtain a new catheter

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil Retention

A nurse is providing teaching about nutrition to an older adult client. The client asks, "Don't I need the same amount of nutrients that I did when I was younger?" Which of the following responses should the nurse make?

Older Adults need an increased amount of calcium. older adults require increased amount of calcium as well as vitamins D, B12, and A.

A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info should the nurse include? Select all. A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins & minerals as younger adults do C. Many older men & women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbs

Older adults are more prone to dehydration than younger adults are Older adults need the same amount of most vitamins & minerals as younger adults do Many older men & women need calcium supplementation Older adults need more calories than they did when they were younger

A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein?

Pepsin Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides.

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications?

Plasma volume expanders helps correct hypovolemia in emergency situations, such as hemorrhage or burns

A nurse is providing teaching to a female client who has a new rx for pravastatin to treat hyperlipidemia. Which of the following pieces of info should the nurse include in the teaching?

Pravastatin can be taken with grapefruit.

A nurse is providing teaching about nutrients to a client. Which of the following statements should the nurse include?

Protein builds and repairs body tissue. The primary functions of proteins involves building and repairing body tissues.

A nurse is planning an in-service training session about nutrition. Which of the following pieces of info should the nurse take?

Protein serves as an energy source when other sources are inadequate

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include?

Protein serves as an energy source when other sources are inadequate.

A nurse is planning care for a client who is post op and has a hx of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1/035. Which of the following actions should the nurse take?

Provide more water with feedings

A nurse is reviewing a client's lab report. The client's ABG levels are pH 7.5. PaCo232 mmHg, and HCO3-24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis.

A nurse is providing teaching an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

Sit on the toilet 30 min after eating a meal. increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 minutes after eating a meal, regardless of feeling the urge to defecate, is recommended method of bowel training to treat constipation.

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs?

Skin

A nurse in a pediatric clinic is talking with the parent of a toddler who states that her child will not sit at the table to eat with the family. She asks the nurse for recommendations for "finger foods" for her child. Which of the following foods should the nurse suggest?

Slices of ripe banana

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium sodium regulates extracellular fluid balance, nerve impulse transmission, acid base balance, and various other cellular activities

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following lab values can cause confusion?

Sodium 123 mEq/L

A nurse is reviewing the lab data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?

Sodium 150mEq/L

A nurse is caring for a client who had xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

Starch

A nurse in the emergency dept is caring for a client who has abd trauma. Which of the following assessment finding should the nurse identify as an indication of hypovolemic shock?

Tachycardia

A nurse is measuring a client's vital signs. The client's HR is 105/min. The nurse should document this finding as which of following alterations?

Tachycardia

A nurse is providing teaching to a client who has gout and urothiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide?

Take allopurinol as prescribed Exercise several times a week Limit intake of foods high in purine

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel. The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take?

Talk with the AP about the technique used

An AP is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder.

A nurse providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching?

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. The RDA represents daily requirements considered adequate for healthy people. RDAs are based on estimated amounts for each nutrient, including additional amounts for individuals such as women or infants.

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvment of the client in planning the change

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include?

Try to block the urge to urinate until the next scheduled time. When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, she should try slow, deep breathing to help reduce the urge. She can also try 5 or 6 strong and quick pelvic muscle exercises.

A nurse is applying antiembolitic stockings for a client who has a hx of deep vein thrombosis. Which of the following actions should the nurse taken when applying the stockings?

Turn the stocking inside out up the heel before applying

A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide?

Use gravies or sauces to soften food

A nurse is caring for a client who requires a low residue diet. The nurse should expect to see which of the following food on the client's meal tray?

Vanilla Custard A low-residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs are appropriate for low residue diet.

a nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure?

Verify the placement of the Ng tube

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe. the client asks the nurse why the water is necessary. Which of the following responses should the nurse make?

Water helps clear the tube so it doesn't get clogged.

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

Wear cotton clothing to avoid static electricity

A nurse is planning care for a client who has fluid volume excess. Which of the following interventions should the nurse place to monitor the client's weight?

Weigh the client on arising

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet?

Whole Milk

A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching?

You can suck on a popsicle to numb your mouth.

A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching.

You should eat dry foods that are high in carbs when you wake up

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

check capillary refill before applying an ice pack to the affected area

A nurse is caring for a client during her prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client?

collard greens

A nurse is caring for a client who has osteoporosis and a new rx for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption?

fortified milk

A nurse is providing dietary teaching to a client who has chronic renal failure. Which of the following food choices by the client indicates an understanding of the teaching?

grilled fish

A nurse is caring for an older adult client who has dementia, gets up frequently to pace during meals, and eats sparingly. Which of the following actions should the nurse take?

provide finger foods for client

A nurse is teaching a client who has lactose intolerance about dietary modifications. Which of the following foods should the nurse recommend?

soy cheese