Question 1

At 7:15 a.m., two assistants in nursing are assigned the task of feeding breakfast to four incapacitated clients. What instruction should the nurse include in this delegation?

Accepted Answer

Engage the client in conversation during the meal.

Question 2

What criteria does the nurse evaluate to determine if an infant's regurgitation, or spitting up, should be further investigated?

Accepted Answer

The nurse should evaluate if the baby is gaining weight adequately. This is because if the baby is gaining weight properly, then the amount and frequency of regurgitation may not be a cause for concern. However, if the baby is not gaining weight or is losing weight, further investigation may be needed to determine if there is an underlying medical issue causing the regurgitation. The other criteria listed may also be considered but are not the best choice as a standalone evaluation.

Question 3

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?

Accepted Answer

A serum glucose level of 328 indicates hyperglycemia and may require adjustment to the TPN prescription. This is especially important because hyperglycemia can lead to complications such as infection and impaired wound healing. While low potassium levels (3.5) and a high BUN (60) may also require attention, they are not as urgent as hyperglycemia. A low prealbumin (15) is a marker of poor nutritional status, but it does not require immediate intervention.

Question 4

Nitrogen balance testing is planned for a newly admitted client. What instruction to the staff caring for this client is essential?

Accepted Answer

Nitrogen balance testing is used to assess protein metabolism and requires accurate measurement of protein intake. Removing the oxygen cannula, collecting urine output, or keeping the client NPO are not essential instructions for this type of testing.

Question 5

A client who is undergoing radiotherapy to her neck may experience nutrition difficulties because:

Accepted Answer

Radiotherapy to the neck can affect the salivary glands and taste buds, leading to a distorted sense of taste, which can impact nutrition.

Question 6

On admission, the client weighs 75 kg. The client reports that this is a weight loss from 82 kg. What is the percent weight loss?

Accepted Answer

The percent weight loss is calculated as [(initial weight - current weight) / initial weight] * 100. So, [(82 kg - 75 kg) / 82 kg] * 100 = 8.5%.

Question 7

The nurse is calculating the body mass index (BMI) of a client admitted to the long-term care facility. The client is 1.75 metres tall and weighs 65 kilograms. What BMI measurement should the nurse document for this client?

Accepted Answer

The answer of The nurse is calculating the body mass...

Question 8

The client reports that her adolescent daughter has started a vegan diet. Which addition to meals should the nurse recommend to help ensure that this adolescent does not become iron deficient?

Accepted Answer

The answer of The client reports that her adolescent daughter...

Question 9

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 for this client?

Accepted Answer

Chicken broth is the best choice for a clear liquid diet after gastrointestinal surgery as it provides some protein and nutrients while being easy to digest. Cranberry and apricot juices have a high sugar content and can cause diarrhea, and tomato juice is acidic and may irritate the digestive system.

Question 10

A nurse is caring for an Arabic client who has severed a tendon in his right hand. The nurse would:

Accepted Answer

Assisting the client to eat his normal diet is the best choice as it respects the client's cultural and dietary preferences. Restricting the use of the right hand or suggesting a specific type of food is not necessary for the client's healing process. Encouraging fluids before meals can be a helpful general recommendation for all clients, but it is not specific to this scenario.

Question 11

The parents of a 7-month-old child have started offering solid foods to their baby. The baby has enjoyed and tolerated rice cereal, applesauce, and other fruits. Which food should the nurse recommend to be introduced next?

Accepted Answer

Pumpkin is a good choice for introducing vegetables to a baby because it is mild in flavor and easy to digest.

Question 12

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?

Accepted Answer

Prealbumin is a marker for recent nutritional status, particularly protein malnutrition, because it has a short half-life, reflecting more immediate nutritional changes than albumin, which has a longer half-life and reflects nutritional status over a longer period. A low prealbumin level indicates recent protein malnutrition.

Question 13

The major dietary source of body energy is:

Accepted Answer

Carbohydrates are the major dietary source of body energy as they are broken down into glucose, which is used by our cells for energy. Proteins and lipids can also provide energy, but they are not as efficient as carbohydrates. Vitamins are essential nutrients required for various metabolic functions, but they do not provide energy. Cholesterol is a type of lipid and does not provide energy.

Question 14

The nurse has instructed an overweight client to follow a 8,360-kilojoule diet by substituting foods considered low in kilojoules for those higher in kilojoules. How does the client interpret the food label to decide if a food is low in kilojoules?

Accepted Answer

According to the information provided, the client should look for foods that are considered low in kilojoules. The most reliable way to determine if a food is low in kilojoules is to look at the nutritional label and check how many kilojoules are in a serving. A food is considered low in kilojoules if it has less than 167 kilojoules per serving. Therefore, the best choice is B. The other options given are incorrect as they do not provide an accurate method for determining if a food is low in kilojoules.

Question 15

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?

Accepted Answer

Total parenteral nutrition (TPN) involves delivering nutrition directly into the bloodstream, bypassing the digestive system. This process can introduce risks of infection, particularly at the catheter insertion site or through contamination of the nutrition solution. Therefore, "Risk for Infection" is a critical nursing diagnosis for patients starting on TPN therapy.

Question 16

The parent of a newborn infant calls the paediatrician's office to report that the baby wakes up every two hours and only takes about 60 mL of formula before going back to sleep. What instruction should the nurse give this parent?

Accepted Answer

Newborn babies often have a small stomach capacity and require frequent feedings to meet their nutritional needs. "On demand" feeding is recommended to ensure that the baby is getting enough formula. It is not recommended to offer less formula to prevent waste or make the baby wait longer than two hours for feeding. Nutritional labelling is important, but not applicable in this situation as the parent has already reported the volume of formula consumed by the baby.

Question 17

The client is weighed each month while residing in the long-term care facility. This month the client weighs 50 kg. The nurse compares this weight to the last three months' results and discovers the client has lost 10 kg. There has been no attempt to lose this weight. How does the nurse interpret this weight loss?

Accepted Answer

The answer of The client is weighed each month while...

Question 18

The nurse has advised the client to consume alcohol only in moderation because:

Accepted Answer

Excessive alcohol consumption can decrease absorption of nutrients, leading to malnutrition. Therefore, consuming alcohol only in moderation is recommended.

Question 19

The client has a body mass index (BMI) of 18. How does the nurse interpret this finding?

Accepted Answer

A BMI of 18 indicates that the client is underweight. A BMI between 18.5-24.9 is considered normal, between 25-29.9 is overweight, and above 30 is obese.

Question 20

A nurse is discussing a daily diet plan with an ethnic client. The nurse should:

Accepted Answer

It is important for the nurse to recognize and respect cultural differences in diet and work with the client to create a plan that meets their needs and preferences. Simply telling the client what is good or bad may not align with their cultural beliefs and could be seen as disrespectful. Referring the client to a dietitian may be helpful, but working collaboratively with the client in the initial discussion is important. Ordering a normal western diet may not meet the client's cultural or nutritional needs.

Quiz 49: Nutrition