Question 1

Unlicensed assistive personnel are assigned the task of feeding breakfast to older clients with alterations in mobility and orientation.What instruction should the nurse include in this delegation?

Accepted Answer

Engaging the client in conversation during the meal can help ensure that the client is alert and oriented, which can reduce the risk of choking and make the experience more pleasant.

Question 2

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

Squash is a good choice for the next solid food as it is a mild-tasting and easily digestible vegetable. It is also a good source of vitamins A and C. Strained beef and chicken may be too rich and difficult for a baby's digestive system to handle, while green beans can cause gas and indigestion.

Question 3

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

Clients who are receiving TPN are at high risk for infection due to the invasive nature of TPN placement and the potential for contamination during administration. The nurse must ensure proper hand hygiene and sterile technique are implemented during catheter insertion and TPN administration to prevent infection. Monitoring for signs and symptoms of infection is also crucial for early detection and intervention. While the other options may be relevant to the client, the risk for infection is the priority when starting TPN therapy.

Question 4

A 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?

Accepted Answer

A clear liquid diet typically consists of liquids that are transparent and free from any solid particles. This diet helps to rest the gastrointestinal system until it recovers from the surgery. Chicken broth is an ideal choice for this type of diet as it is low in fat and easy to digest. It also provides the client with essential nutrients such as protein and amino acids to support healing. Apricot nectar, cranberry juice, and cherry ice pop are not appropriate choices for a clear liquid diet as they contain solid particles and/or high amounts of sugar.

Question 5

The nurse notes that the tube-fed client has shallow breathing and dusky color.The feeding is running at the prescribed rate.What should the nurse do first?

Accepted Answer

Shallow breathing and dusky color in a tube-fed client may indicate aspiration, which is a serious complication. The first step is to turn off the tube feeding to prevent further aspiration. The nurse can then assess the client's breathing and lung sounds, as well as notify the healthcare provider and implement interventions as necessary, such as suctioning or supplemental oxygen. Placing the client in high Fowler's position or assessing bowel sounds may be appropriate later, but turning off the tube feeding is the priority to prevent further complications.

Question 6

A client reports following the "food pyramid" to guide nutritional intake.How should the nurse evaluate this information?

Accepted Answer

While following the appropriate food pyramid can be helpful, there are additional factors to consider in a balanced diet such as fluid intake and combination of foods. It is important to assess the client's overall nutritional intake and make individualized recommendations. The food pyramid may also not be appropriate for everyone, such as those with certain medical conditions or dietary restrictions.

Question 7

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

Accepted Answer

Accurate measurement of food intake is essential for nitrogen balance testing as it measures the amount of nitrogen consumed and excreted in urine and feces. Removing oxygen cannula, collecting urine output for 48 hours, and keeping the client NPO are not relevant to the test.

Question 8

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?

Accepted Answer

Checking the tube for correct placement is a nursing responsibility that cannot be delegated to a UAP. The nurse must ensure that the UAP has received appropriate training and education before delegating any task to them, but the nurse should not order the equipment or set up the feeding. Regulating the rate of the feeding may also be a nursing responsibility depending on the patient's condition and needs.

Question 9

The parent of a newborn infant reports that the baby wakes up every 2 hours and only takes about 2 ounces of formula before going back to sleep.What instruction should the nurse give this parent?

Accepted Answer

At this age, newborns need to be fed on demand and every 2-3 hours is typical. The baby is taking in enough formula to satisfy hunger and promote growth. It is important to continue feeding the baby on an on-demand schedule to ensure adequate nutrition and growth.

Question 10

The nurse is instructing a client on foods that are considered complete proteins.What will the nurse include in these instructions?
Standard Text: Select all that apply.

Accepted Answer

Meat, eggs, chicken, and fish are all considered complete proteins because they contain all nine essential amino acids that the body cannot produce on its own. Gelatin, on the other hand, is not considered a complete protein as it does not contain all nine essential amino acids.

Question 11

During diet teaching with a client diagnosed with diabetes,the nurse should instruct that the most prevalent monosaccharide is

Accepted Answer

Glucose is the most prevalent monosaccharide and the primary source of energy for the body. It is important for clients with diabetes to monitor their glucose levels and manage their intake of carbohydrates, particularly foods high in glucose. Fructose and galactose are also monosaccharides but are less prevalent in the diet. Corn syrup is a type of sweetener made from cornstarch and often contains high levels of glucose and fructose.

Question 12

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 should the nurse interpret this weight loss?

Accepted Answer

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

Question 13

The nurse is preparing to insert a nasogastric tube into a client.In what order will the nurse conduct the following steps?
Standard Text: Click and drag the options below to move them up or down.

Accepted Answer

First, ask the client to hyperextend their neck to straighten the path from the nose to the stomach. Second, ask the client to tilt their head forward, which aids in the insertion of the tube. Third, have the client swallow a small amount of liquid to help guide the tube into the esophagus. Fourth, insert the tube with its natural curve toward the client, and finally, employ a slight twisting motion on the tube to help advance it through the lower esophageal sphincter.

Question 14

A client reports that an adolescent family member has started a vegan diet.Which additions to meals should the nurse recommend to help ensure that the adolescent does not become deficient in calcium?
Standard Text: Select all that apply.

Accepted Answer

The answer of A client reports that an adolescent family...

Question 15

The nurse notices that the client's continuous open system tube-feeding set is almost empty.What action should the nurse take?

Accepted Answer

The answer of The nurse notices that the client's continuous...

Question 16

As the nasogastric tube is passed into the oropharynx,the client begins to gag and cough.What is the correct nursing action?

Accepted Answer

Giving the client a few sips of water can help facilitate the passage of the nasogastric tube by encouraging swallowing, which can help guide the tube into the esophagus rather than the airway.

Question 17

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

Accepted Answer

According to guidelines from the National Institute on Alcohol Abuse and Alcoholism, moderate alcohol intake is defined as one drink per day for women and up to two drinks per day for men. Therefore, the nurse should advise the client to consume no more than one drink per day if they want to follow a moderate alcohol intake pattern. Choices A, B, and D suggest exceeding the recommended limits for moderate alcohol intake.

Question 18

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

Accepted Answer

Adequate weight gain is the most important criteria to rule out any serious underlying condition related to frequent spitting up.

Answer: D
 The consistency of the regurgitated matter can provide clues about any underlying digestive or other problems that can cause spitting up, which may need further investigation.

Therefore, the best choices are C and D.

Question 19

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 should the client interpret the food label to decide if a food is low in calories?

Accepted Answer

Nutritional labeling on the product will indicate less than 40 calories per serving. This is the most accurate way to determine if a food is considered low in calories. The other options may not always be reliable indicators of a food's calorie content.

Question 20

The nurse completes triceps skinfold measurement on a client.In order to obtain the most meaningful data,how soon should the nurse repeat this measurement?

Accepted Answer

The answer of The nurse completes triceps skinfold measurement on...

Quiz 47: Nutrition