-
The nurse has advised the client to consume
alcohol only in moderation. What guideline should the nurse provide as a "moderate"
alcohol intake?
- A. Two drinks per week for women, three for men
- B. Two drinks per day for women, three for men
- C. * One drink per day for women, two for men D. One drink per week for women, two for men
-
The nurse completes triceps skinfold measurement
on a client newly admitted to the long-term care facility. In order to obtain
the most meaningful data, how soon should the nurse repeat this measurement?
- A. Two days
- B. Ten days to two weeks
- C. One month
- D. * One year
-
The client's lab studies reveal a normal serum
albumin with a prealbumin of 10. How does the nurse interpret the significance
of these readings?
- A. * Thenclient has had recent protein malnutrition.
- B. The client is now relatively well nourished withmalnutrition 6 to 8 months ago.
- C. The client is at risk for development of malabsorptionmsyndromes.
- D. Carbohydrate malnutrition has occurred over the last 6 months.
-
The client reports following the "food
pyramid" to guide nutritional intake. How should the nurse evaluate this
information?
- A. Since this food pyramid is produced by the U.S. Department of Agriculture, the client
- is likely consuming necessary levels of all essential nutrients.
- B. The food pyramid is most useful when applied to the nutritional intake of children.
- C. The food pyramid is not very useful because it does nottake fluid intake and combination foods into consideration.
- D. * Following the appropriate food pyramid
- is helpful, but there are additional factors to consider in a balanced diet.
-
The nurse has instructed an overweight client to
follow a 2,000-calorie diet by substituting foods considered low in calories
for those higher in calories. How does the client interpret the food label to decide if a food is low in calories?
- A. The product label will state "lighter" or "reduced calories."
- B. The nutrition facts label will have the letter
- "L" located in the lower right corner.
- C. * Nutritional labeling on the product will
- indicate less than 40 calories per serving.
- D. The product will contain no more than 11% fat.
-
The client reports that her teenager has started
a vegan diet. Which addition to meals should the nurse recommend to help ensure
that this teenager does not become iron deficient? (Select all that apply.)
- A. Tofu
- B. Soybean milk
- C. Brewer's yeast
- D. Orange juice
- E. Okra
-
Nitrogen balance testing is planned for a newly
admitted client. What instruction to the staff caring for this client is
essential?
- A. Remove the client's oxygen cannula 10 minutes prior to the test.
- B. * Accurate measurement of food intake is
- very important.
- C. All urine output should be collected for 48 hours.
- D. Keep the client NPO beginning at midnight before the test.
-
The client who has undergone a gastrointestinal
surgery is permitted to have a clear liquid diet on the second postoperative
day. Which fluid should the nurse order from the diet kitchen for this client?
- A. Apricotnectar
- B. Cranberry juice
- C. * Chicken broth
- D. Cherry ice pop
-
At7:15 AM, two unlicensed personnel are assigned the task of feeding breakfast to
four incapacitated clients. What instruction should the nurse include in this
delegation?
- A. Breakfast should be completed by 8:00 AM so that baths may begin.
- B. Give fluids before and after each bite of solid foods.
- C. Stand to the left of right-handed clients during feeding.
- D. * Engage the client in conversation during
- the meal.
-
What instruction does the nurse give the client as the nasogastric tube is being
removed?
-
The nurse has delegated administration of tube
feeding to a specially trained UAP. What action should be taken by the nurse in
regard to this delegation?
- A. Order the equipment to give the feeding.
- B. * Check the tube for placement.
- C. Set up the equipment and mix the feeding.
- D. Regulate the rate of the feeding.
-
The nurse notices that the client's continuous
open system tube-feeding set is almost empty. What action should the nurse
take?
- A. Add tube feeding to the set.
- B. Discontinue the feeding and hang a closed system bag.
- C. * Wash out the set and add new feeding.
- D. Flush the set with clear carbonated soda and discontinue.
-
As
the nasogastric tube is passed into the oropharynx, the client begins to gag
and cough. What is the correct nursing action?
- A. Remove the tube and attempt reinsertion.
- B. * Give the client a few sips of water.
- C. Use firm pressure to pass the tube through the glottis.
- D. Have the client tilt the head back to open the passage.
-
The nurse notes that the tube-fed client has
shallow breathing and dusky color. The feeding is running at the prescribed
rate. What is the nurse's priority action?
- A. place the client in high
- Fowler's position.
- B. * Turn off the tube feeding.
- C. Assess the client's lung sounds.
- D. Assess the client's bowel sounds.
-
The nurse is calculating the body mass index
(BMI) of a client admitted to the long-term care facility. The client is 1.75
meters tall and weighs 65 kilograms. What BMI measurement should the nurse
document for this client? __________
-
The client has a body mass index (BMI) of 18. How does the nurse interpret this finding?
- A. Theclient is malnourished.
- B. * The client is underweight.
- C. The client is normal.
- D. The client is overweight.
-
On admission, the client weighs 165 lb (75 kg). The client reports that this is a weight loss from 180 lb (82 kg). What is the percent weight loss?
- A. 4.5%
- B. 6.25%
- C. * 8.3%
- D. 10.0%
-
The client is weighed each month while residing
in the long-term care facility. This month the client weighs 110 lb (50 kg).
The nurse compares this weight to the last 3 months' results and discovers the
client has lost 22 lb (10 kg). There has been no attempt to lose this weight.
How does the nurse interpret this weight loss?
- A. No malnutrition
- B. * Mild malnutrition
- C. Moderate malnutrition
- D. Severe malnutrition ????????????????????????????????????????
-
The client who was started on total parenteral
nutrition (TPN) yesterday has the following morning lab results. Which result indicates the greatest urgency for the nurse's collaboration with the physician?
- A. BUN of 60
- B. Prealbumin of 15
- C. * Serum glucose of 328
- D. Potassium of 3.5
-
What nursing diagnosis is the most important for
the nurse to include in the care plan of a client who has just been started on total parenteral nutrition (TPN) therapy?
- A. * Riskfor Infection
- B. Imbalanced Nutrition: Less than Body Requirements
- C. Activity Intolerance
- D. Fluid Volume Deficit
-
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