The nurse has advised the client to consume
alcohol only in moderation. What guideline should the nurse provide as a "moderate"
- 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
- 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
- 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
- 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
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
- 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.
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