Chapter 47 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 47

Question 1

Type: MCSA

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?

1. Make the baby wait at least 3 hours between feedings.

2. Continue to feed the baby with this on demand schedule.

3. When the baby gets sleepy during feeding, use techniques such as moving around and tickling to encourage wakefulness.

4. Offer the baby less formula to prevent waste.

Correct Answer: 2

Rationale 1: Making the baby wait longer between feedings may result in feeding difficulties later in childhood.

Rationale 2: Newborns are often fed following an on demand schedule. This might include feedings every 2 hours at first.

Rationale 3: Trying to keep the baby awake to feed may result in feeding difficulties later in childhood.

Rationale 4: Offering less formula may result in feeding difficulties later in childhood.

Global Rationale: Page Reference: 1257

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify nutritional variations throughout the life cycle.

Question 2

Type: MCSA

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

1. How often the baby spits up

2. How much the baby spits up at a time

3. If the baby is gaining weight adequately

4. The consistency of the regurgitated matter

Correct Answer: 3

Rationale 1: Many babies spit up after every meal and some seem to spit up a great deal.

Rationale 2: How much the baby spits up at a time is not included in criteria to evaluate if the regurgitation should be further investigated.

Rationale 3: As long as the baby is gaining weight adequately, it is not abnormal for regurgitation or spitting up to occur.

Rationale 4: The consistency of the regurgitated material may be thin (just consumed) or curdled (has been partially digested) and either case is normal.

Global Rationale: Page Reference: 1258

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 04 Identify nutritional variations throughout the life cycle.

Question 3

Type: MCSA

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?

1. Strained beef

2. Green beans

3. Squash

4. Strained chicken

Correct Answer: 3

Rationale 1: Meat should be introduced last.

Rationale 2: Yellow vegetables should be offered before green vegetables.

Rationale 3: As the baby develops, foods are offered in the sequence in which they are generally best tolerated. Most experts recommend introducing cereals, fruits, yellow vegetables (squash), green vegetables (green beans), and then meats.

Rationale 4: Meat products should be introduced last.

Global Rationale: Page Reference: 1258

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify nutritional variations throughout the life cycle.

Question 4

Type: MCSA

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

1. Two drinks per week for women, three for men

2. Two drinks per day for women, three for men

3. One drink per day for women, two for men

4. One drink per week for women, two for men

Correct Answer: 3

Rationale 1: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men.

Rationale 2: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men.

Rationale 3: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men.

Rationale 4: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men.

Global Rationale: Page Reference: 1257

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe nursing interventions to promote optimal nutrition.

Question 5

Type: MCSA

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?

1. Two days

2. Ten days to two weeks

3. One month

4. One year

Correct Answer: 4

Rationale 1: The changes in this measurement occur so slowly that remeasuring in 2 days would not provide significant data.

Rationale 2: The changes in this measurement occur so slowly that remeasuring in 10 days to 2 weeks, would not provide significant data.

Rationale 3: The changes in this measurement occur so slowly that remeasuring in 1 month would not provide significant data.

Rationale 4: Anthropometric measurements such as triceps skinfold measurement provide the most meaningful data when monitored over longer periods of time such as several months to years.

Global Rationale: Page Reference: 1274

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional problems.

Question 6

Type: MCSA

The clients lab studies reveal a normal serum albumin with a prealbumin of 10. How does the nurse interpret the significance of these readings?

1. The client has had recent protein malnutrition.

2. The client is now relatively well nourished with malnutrition 6 to 8 months ago.

3. The client is at risk for development of malabsorption syndromes.

4. Carbohydrate malnutrition has occurred over the last 6 months.

Correct Answer: 1

Rationale 1: Prealbumin is the most responsive serum protein to rapid changes in nutritional status. A level below 11 indicates that aggressive nutritional intervention is necessary.

Rationale 2: Serum albumin is the slowest of the serum proteins to reflect changes, so abnormalities indicate prolonged protein malnutrition.

Rationale 3: There is no specific link to malabsorption syndromes.

Rationale 4: These tests are indicators of protein malnutrition, not carbohydrate malnutrition.

Global Rationale: Page Reference: 1275

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional problems.

Question 7

Type: MCSA

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

1. Since this food pyramid is produced by the U.S. Department of Agriculture, the client is likely consuming necessary levels of all essential nutrients.

2. The food pyramid is most useful when applied to the nutritional intake of children.

3. The food pyramid is not very useful because it does not take fluid intake and combination foods into consideration.

4. Following the appropriate food pyramid is helpful, but there are additional factors to consider in a balanced diet.

Correct Answer: 4

Rationale 1: Overall, the food pyramid is a good guide, but unless the client eats a variety of foods from each group, some recommended nutrient levels may be missed.

Rationale 2: Food pyramids are available for different age groups, including children, middle adults, and older adults.

Rationale 3: The food pyramid does not take fluid intake and activity level into consideration.

Rationale 4: Since there are numerous food pyramids, the client should be following the appropriate one, and other factors such as fluid intake and activity level should be considered in planning a balanced diet.

Global Rationale: Page Reference: 1265

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 05 Evaluate a diet using a food guide pyramid.

Question 8

Type: MCSA

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?

1. The product label will state lighter or reduced calories.

2. The nutrition facts label will have the letter L located in the lower right corner.

3. Nutritional labeling on the product will indicate less than 40 calories per serving.

4. The product will contain no more than 11% fat.

Correct Answer: 3

Rationale 1: The words lighter or reduced calories only mean that this version of the food is lower in calories than a previous version, but the food can still be very high in calories.

Rationale 2: There is no special label letter that indicates foods lighter in calories.

Rationale 3: In order to qualify as a low-calorie food in a 2,000-calorie diet, the food must have less than 40 calories per serving.

Rationale 4: Foods that are lower in fat also contain fewer calories, but low fat is considered less than 5%.

Global Rationale: Page Reference: 1268-1269

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional problems.

Question 9

Type: MCSA

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

1. Remove the clients oxygen cannula 10 minutes prior to the test.

2. Accurate measurement of food intake is very important.

3. All urine output should be collected for 48 hours.

4. Keep the client NPO beginning at midnight before the test.

Correct Answer: 2

Rationale 1: The presence of an oxygen cannula is not associated with preparation for the test.

Rationale 2: Nitrogen balance is determined by comparing the grams of protein taken in to the urinary nitrogen output for 24 hours. Accurate food intake is essential.

Rationale 3: Urine output is not collected for 48 hours for this test.

Rationale 4: The client must have protein intake during the testing time.

Global Rationale: Page Reference: 1270

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional
problems.

Question 10

Type: MCSA

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?

1. Apricot nectar

2. Cranberry juice

3. Chicken broth

4. Cherry ice pop

Correct Answer: 3

Rationale 1: Apricot nectar is thick with pulp.

Rationale 2: Cranberry juice is red. Clients who have undergone gastrointestinal surgery are often not allowed to have red liquids because the color can be confused with blood if the client vomits.

Rationale 3: Chicken broth is the only liquid listed that is clear and not red.

Rationale 4: A cherry ice pop is red. Clients who have undergone gastrointestinal surgery are often not allowed to have red liquids because the color can be confused with blood if the client vomits.

Global Rationale: Page Reference: 1280

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional
problems.

Question 11

Type: MCSA

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?

1. Breakfast should be completed quickly so that baths may begin.

2. Give fluids before and after each bite of solid foods.

3. Stand to the left of right-handed clients during feeding.

4. Engage the client in conversation during the meal.

Correct Answer: 4

Rationale 1: It may well take over 45 minutes to feed these clients in an unhurried manner.

Rationale 2: Fluids should be offered when the client requests fluids, or after three to four bites of food.

Rationale 3: The personnel should sit while feeding the client to convey a relaxed and unhurried atmosphere.

Rationale 4: Of the options given, the best answer is to engage the client in conversation during the meal. This makes the mealtime pleasant and encourages socialization as well as appetite.

Global Rationale: Page Reference: 1280-1281

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional
problems.

Question 12

Type: SEQ

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.

Choice 1. Ask the client to tilt the head forward.

Choice 2. Insert the tube with its natural curve toward the client.

Choice 3. Ask the client to hyperextend the neck.

Choice 4. Have the client swallow a small amount of liquid.

Choice 5. Employ a slight twisting motion on the tube.

Correct Answer: 2,3,5,1,4

Rationale 1: At this time, have the client tilt the head forward to facilitate passage of the tube into the posterior pharynx and esophagus.

Rationale 2: The tube should first be inserted with its natural curve toward the client.

Rationale 3: At this time, having the client hyperextend the neck will reduce the curvature of the nasopharyngeal junction.

Rationale 4: The client should then be asked to swallow to move the epiglottis over the opening of the larynx, directing the tube toward the esophagus.

Rationale 5: A slight twisting motion may help pass the tube into the nasopharynx.

Global Rationale: Page Reference: 1284

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Verbalize the steps used in:
a. Inserting a nasogastric tube.

Question 13

Type: MCSA

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?

1. Order the equipment to give the feeding.

2. Check the tube for placement.

3. Set up the equipment and mix the feeding.

4. Regulate the rate of the feeding.

Correct Answer: 2

Rationale 1: The nurse is responsible to assess tube placement and to determine that the tube is patent. The UAP can order equipment.

Rationale 2: The nurse is responsible to assess tube placement and to determine that the tube is patent.

Rationale 3: The UAP can set up equipment and mix the feeding.

Rationale 4: The UAP can order equipment regulate the rate of feeding.

Global Rationale: Page Reference: 1284

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Recognize when it is appropriate to delegate aspects of feeding clients to unlicensed assistive personnel.

Question 14

Type: MCSA

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

1. Add tube feeding to the set.

2. Discontinue the feeding and hang a closed system bag.

3. Wash out the set and add new feeding.

4. Flush the set with clear carbonated soda and discontinue.

Correct Answer: 3

Rationale 1: Feeding is not added to that which has already been hanging.

Rationale 2: There is no indication to change the type of feeding to a closed system.

Rationale 3: The open set should be taken down, washed well, and rehung with new feeding.

Rationale 4: Carbonated soda should not be used to irrigate the tube as it can lead to occlusion.

Global Rationale: Page Reference: 1289-1290

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Verbalize the steps used in:
c. Administering a tube feeding.

Question 15

Type: MCSA

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

1. Remove the tube and attempt reinsertion.

2. Give the client a few sips of water.

3. Use firm pressure to pass the tube through the glottis.

4. Have the client tilt the head back to open the passage.

Correct Answer: 2

Rationale 1: This is a common response to the presence of a tube in the oropharynx, so removal of the tube is not necessary.

Rationale 2: Swallowing ice or water may help calm the gag reflex and also facilitate the swallowing of the tube.

Rationale 3: The nurse should not use pressure to pass the tube.

Rationale 4: The clients head should be tilted forward at this point. Tilting the head back will open the airway, not the esophagus.

Global Rationale: Page Reference:1284

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Verbalize the steps used in:
a. Inserting a nasogastric tube.

Question 16

Type: MCSA

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 nurses priority action?

1. Place the client in high Fowlers position.

2. Turn off the tube feeding.

3. Assess the clients lung sounds.

4. Assess the clients bowel sounds.

Correct Answer: 2

Rationale 1: This action is not the priority.

Rationale 2: These findings indicate possible aspiration of the feeding. The priority action is to discontinue the feeding to eliminate the amount of material going into the clients lungs. This should be done before any further assessment or client position change is attempted. If it is discovered that there is no aspiration, the tube feeding can be restarted.

Rationale 3: This is not the priority action.

Rationale 4: This is not the priority action.

Global Rationale: Page Reference:1285

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12 Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems.

Question 17

Type: MCSA

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

1. The client is malnourished.

2. The client is underweight.

3. The client is normal.

4. The client is overweight.

Correct Answer: 2

Rationale 1: Clients who have a BMI less than 16 are considered malnourished.

Rationale 2: A BMI of 18 falls within the category of being underweight (16-19).

Rationale 3: Clients with a BMI of 20-25 are considered normal.

Rationale 4: A BMI of 26-30 is considered overweight.

Global Rationale: Page Reference:1253

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12 Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems.

Question 18

Type: MCSA

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?

1. 4.5%

2. 6.25%

3. 8.3%

4. 10.0%

Correct Answer: 3

Rationale 1: To calculate the percent weight loss, subtract the current weight (165 lb) from the usual weight (180 lb). Divide the result by the usual weight and multiply that result by 100. In this case, the loss is 8.3%.

Rationale 2: To calculate the percent weight loss, subtract the current weight (165 lb) from the usual weight (180 lb). Divide the result by the usual weight and multiply that result by 100. In this case, the loss is 8.3%.

Rationale 3: To calculate the percent weight loss, subtract the current weight (165 lb) from the usual weight (180 lb). Divide the result by the usual weight and multiply that result by 100. In this case, the loss is 8.3%.

Rationale 4: To calculate the percent weight loss, subtract the current weight (165 lb) from the usual weight (180 lb). Divide the result by the usual weight and multiply that result by 100. In this case, the loss is 8.3%.

Global Rationale: Page Reference: 1253-1254

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Discuss essential components and purposes of nutritional assessment and nutritional screening.

Question 19

Type: MCSA

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?

1. No malnutrition

2. Mild malnutrition

3. Moderate malnutrition

4. Severe malnutrition

Correct Answer: 2

Rationale 1: To calculate the level of nutritional deficit, the nurse first figures the current percentage of usual body weight and then compares that result to nutritional standards. To calculate the percent of usual body weight, divide the current weight by the usual body weight and multiply by 100. In this case, the client is at 91% of usual body weight. Mild malnutrition is 85% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This is particularly important in an unintentional weight loss.

Rationale 2: To calculate the level of nutritional deficit, the nurse first figures the current percentage of usual body weight and then compares that result to nutritional standards. To calculate the percent of usual body weight, divide the current weight by the usual body weight and multiply by 100. In this case, the client is at 91% of usual body weight. Mild malnutrition is 85% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This is particularly important in an unintentional weight loss.

Rationale 3: To calculate the level of nutritional deficit, the nurse first figures the current percentage of usual body weight and then compares that result to nutritional standards. To calculate the percent of usual body weight, divide the current weight by the usual body weight and multiply by 100. In this case, the client is at 91% of usual body weight. Mild malnutrition is 85% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This is particularly important in an unintentional weight loss.

Rationale 4: To calculate the level of nutritional deficit, the nurse first figures the current percentage of usual body weight and then compares that result to nutritional standards. To calculate the percent of usual body weight, divide the current weight by the usual body weight and multiply by 100. In this case, the client is at 91% of usual body weight. Mild malnutrition is 85% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This is particularly important in an unintentional weight loss.

Global Rationale: Page Reference:1276

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12 Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems.

Question 20

Type: MCSA

The nurse is reviewing laboratory data for a client who is receiving total parenteral nutrition. Which laboratory value should be immediately brought to the physicians attention?

1. BUN of 60

2. Prealbumin of 15

3. Serum glucose of 328

4. Potassium of 3.5

Correct Answer: 3

Rationale 1: This laboratory value does not need to be immediately brought to the physicians attention.

Rationale 2: This laboratory value does not need to be immediately brought to the physicians attention.

Rationale 3: The most important concern in this set of laboratory data is the increased serum glucose.

Rationale 4: The potassium reading is normal.

Global Rationale: Page Reference:1296, 1297

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify risk factors for and clinical signs of malnutrition.

Question 21

Type: MCSA

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?

1. Risk for Infection

2. Imbalanced Nutrition: Less than Body Requirements

3. Activity Intolerance

4. Fluid Volume Deficit

Correct Answer: 1

Rationale 1: TPN is delivered via a venous catheter and is very high in glucose. There is a very high risk for infection.

Rationale 2: The client already has imbalanced nutrition, so while that nursing diagnosis would be included, it is not as important as the risk for infection. The TPN therapy is already addressing the imbalanced nutrition.

Rationale 3: The client may have an activity intolerance, but the risk for infection takes priority as it can cause greater physical harm to the client.

Rationale 4: The client is now at more risk of fluid volume overload from the additional TPN fluid.

Global Rationale: Page Reference:1278, 1297

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12 Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems.

Question 22

Type: MCMA

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 iron-deficient?

Standard Text: Select all that apply.

1. Tofu.

2. Soybeans.

3. Brewers yeast.

4. Raisins.

5. Okra.

6. Apples.

Correct Answer: 1,2,4

Rationale 1: While all these options are good ones for someone on a vegan diet, the ones that would best prevent iron deficiency include tofu, with 1.9 mg of iron in a cup.

Rationale 2: While all these options are good ones for someone on a vegan diet, the ones that would best prevent iron deficiency include soybeans, with 2.8 mg of iron in 3 ounces.

Rationale 3: There is no information to determine the amount of iron in Brewers yeast.

Rationale 4: While all these options are good ones for someone on a vegan diet, the ones that would best prevent iron deficiency include raisins, with 3.5 mg of iron in two thirds of a cup.

Rationale 5: Okra does not have an appreciable amount of iron.

Rationale 6: Apples do not have an appreciable amount of iron.

Global Rationale: Page Reference:1269

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe nursing interventions to promote optimal nutrition.

Question 23

Type: MCSA

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

1. Fructose.

2. Galactose.

3. Corn syrup.

4. Glucose.

Correct Answer: 4

Rationale 1: Fructose is not as abundant as is glucose.

Rationale 2: Galactose is not as abundant as is glucose.

Rationale 3: Corn syrup is considered a processed sugar.

Rationale 4: Of the three monosaccharidesglucose, fructose, and galactoseglucose is by far the most abundant simple sugar.

Global Rationale: Page Reference:1250

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Identify essential nutrients and their dietary sources.

Question 24

Type: MCMA

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.

1. Meat.

2. Gelatin.

3. Eggs.

4. Chicken.

5. Fish.

Correct Answer: 1,3,4,5

Rationale 1: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including meats, are complete proteins.

Rationale 2: Some animal proteins contain less than the required amount of one or more essential amino acids, and therefore cannot support continued growth alone. These proteins are sometimes referred to as partially complete proteins. Gelatin is an incomplete protein.

Rationale 3: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including eggs, are complete proteins.

Rationale 4: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including poultry, are complete proteins.

Rationale 5: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including fish, are complete proteins.

Global Rationale: Page Reference:1251

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Identify essential nutrients and their dietary sources.

Question 25

Type: MCMA

A client is diagnosed with an elevated cholesterol level. What should the nurse instruct the client regarding foods to avoid?

Standard Text: Select all that apply.

1. Fish.

2. Milk.

3. Liver.

4. Chicken.

5. Egg yolk.

Correct Answer: 2,3,5

Rationale 1: Cholesterol is not as prevalent in fish.

Rationale 2: Cholesterol is found in milk.

Rationale 3: Cholesterol is found in organ meats, such as liver.

Rationale 4: Cholesterol is not as prevalent in chicken.

Rationale 5: Cholesterol is found in egg yolks.

Global Rationale: Page Reference:1251

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional problems.

Question 26

Type: MCMA

The nurse is planning an educational program for community members on ways to improve nutritional intake. What information should the nurse include about carbohydrate digestion and metabolism?

Standard Text: Select all that apply.

1. Enzymes are needed to digest carbohydrates.

2. The breakdown of carbohydrates results in simple sugars.

3. Carbohydrates are a major source of body energy.

4. The simple sugar glucose provides a readily available source of energy.

5. Pancreatic amylase enhances the use of glucose by the body cells.

Correct Answer: 1,2,3,4

Rationale 1: Major enzymes of carbohydrate digestion speed up chemical reactions.

Rationale 2: The desired end products of carbohydrate digestion are monosaccharides. Some simple sugars are already monosaccharides, and require no digestion.

Rationale 3: Carbohydrate metabolism is a major source of body energy.

Rationale 4: After the body breaks carbohydrates down into glucose, some glucose continues to circulate in the blood to maintain blood levels and to provide a readily available source of energy.

Rationale 5: Insulin, a hormone secreted by the pancreas, enhances the transport of glucose into cells.

Global Rationale: Page Reference:1250

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 02 Describe normal digestion, absorption, and metabolism of carbohydrates, proteins, and lipids.

Question 27

Type: MCSA

A client is diagnosed as having a negative nitrogen balance. How should the nurse instruct the client about this finding?

1. Discuss ways to reduce protein in the diet.

2. Review how to limit carbohydrates in the diet.

3. Discuss ways to increase protein in the diet.

4. Analyze reasons why fats should be limited in the diet.

Correct Answer: 3

Rationale 1: This would further decrease the clients protein stores, worsening the nitrogen balance.

Rationale 2: Nitrogen balance does not measure carbohydrate intake in the diet.

Rationale 3: Nitrogen balance means the amounts of protein anabolism and protein catabolism are equal. In negative nitrogen balance, there is an excessive amount of protein catabolism or a decrease in the amount of protein ingested in the diet.

Rationale 4: Fat intake does not influence nitrogen balance.

Global Rationale: Page Reference:1251

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional problems.

Question 28

Type: MCSA

A client diagnosed with negative nitrogen balance tells the nurse about participating in ritualistic fasts as a part of their culture. The client abstains from all food for several days at a time. What should the nurse discuss with the client regarding this practice?

1. The amount of weight the client will lose during the fasts.

2. The need to ingest some carbohydrates for body functions.

3. The amount of calories the client will need to ingest after fasting for several days.

4. The importance of the practice to the client.

Correct Answer: 2

Rationale 1: The clients weight loss is not as important as is the harm the fast is doing to the clients protein stores and nitrogen balance.

Rationale 2: A person who fasts will obtain most of his calories from fat metabolism, but some of the bodys carbohydrate and protein stores must be used to support brain, nerve, and red blood cell function. The nurse should discuss with the client reasons to ingest carbohydrates to preserve the clients protein stores during the ritualistic fasts.

Rationale 3: The clients need for increased caloric intake after the fast is not as important as is the harm the fast is doing to the clients protein stores and nitrogen balance.

Rationale 4: The importance of the practice to the client is not as important as is the harm the fast is doing to the clients protein stores and nitrogen balance.

Global Rationale: Page Reference:1251

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional problems.

Question 29

Type: MCMA

A client asks the nurse for help selecting food, since some are good and others are bad. How should the nurse respond to the client?

Standard Text: Select all that apply.

1. Eat a wide variety of foods to furnish adequate nutrients.

2. Avoid starchy foods.

3. Limit foods with high-fructose corn syrup.

4. Eat three meals a day to reduce calories.

5. Eat moderately to maintain correct body weight.

Correct Answer: 1,5

Rationale 1: Nurses should not use a good food, bad food approach, but rather should realize that variations of intake are acceptable under different circumstances. The only universally accepted guidelines are to eat a wide variety of foods to furnish adequate nutrients.

Rationale 2: The nurse should not support the clients belief about foods being either good or bad.

Rationale 3: The nurse should not support the clients belief about foods being either good or bad.

Rationale 4: This might not be enough to sustain the clients calorie needs.

Rationale 5: Nurses should not use a good food, bad food approach, but rather should realize that variations of intake are acceptable under different circumstances. The only universally accepted guidelines are to eat moderately to maintain correct body weight.

Global Rationale: Page Reference:1269

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Identify essential nutrients and their dietary sources.

Question 30

Type: MCSA

A client tells the nurse that fresh fruit should be eaten only on an empty stomach, since it will cause other foods to ferment in the stomach. The nurse realizes this clients nutritional status is influenced by:

1. Lifestyle.

2. Culture.

3. Beliefs about food.

4. Religious practices.

Correct Answer: 3

Rationale 1: Certain lifestyles are linked to food-related behaviors. People who are always in a hurry probably buy convenience grocery items or eat restaurant meals. People who spend many hours at home might take time to prepare more meals from scratch.

Rationale 2: Ethnicity often determines food preferences. Traditional foods are eaten long after other customs are abandoned.

Rationale 3: Beliefs about effects of foods on health and well-being can affect food choices. Many people acquire their beliefs about food from television, magazines, and other media. Food fads that involve nontraditional food practices are relatively common.

Rationale 4: Religious practice also affects diet. In some religions, meat is avoided on certain days. In some faiths, meat, tea, coffee, and/or alcohol are prohibited.

Global Rationale: Page Reference:1254

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify factors influencing nutrition.

Question 31

Type: MCMA

The nurse is planning instruction for a client who is underweight. What should be included in this teaching?

Standard Text: Select all that apply.

1. Discuss factors contributing to inadequate nutrition and weight loss.

2. Discuss ways to manage, minimize, or alter the factors contributing to malnourishment.

3. Discuss principles of a well-balanced diet and high- and low-calorie foods.

4. Provide information about community agencies that can assist in providing food.

5. Provide information about ways to increase calorie intake.

Correct Answer: 1,2,4,5

Rationale 1: Client teaching for underweight clients should include a discussion of the factors contributing to inadequate nutrition and weight loss.

Rationale 2: Client teaching for underweight clients should include a discussion of ways to manage, minimize, or alter the factors contributing to malnourishment.

Rationale 3: Client teaching for overweight clients should include the principles of a well-balanced diet and high- and low- calorie foods.

Rationale 4: Client teaching for underweight clients should include information about community agencies that can assist in providing food.

Rationale 5: Client teaching for underweight clients should include information about ways to increase caloric intake.

Global Rationale: Page Reference:1269

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Describe nursing interventions to promote optimal nutrition.

Question 32

Type: MCMA

The nurse is planning interventions for a client to improve the appetite. What actions would be appropriate for this client?

Standard Text: Select all that apply.

1. Select small portions.

2. Avoid unpleasant treatments immediately before or after a meal.

3. Ensure a clean environment free of unpleasant sights and odors.

4. Encourage oral hygiene before a meal.

5. Provide medication for pain or other symptoms after a meal.

Correct Answer: 1,2,3,4

Rationale 1: Interventions to improve a clients appetite include selecting small portions.

Rationale 2: Interventions to improve a clients appetite include avoiding unpleasant treatments immediately before or after a meal.

Rationale 3: Interventions to improve a clients appetite include ensuring a clean environment that is free of unpleasant sights and odors.

Rationale 4: Interventions to improve a clients appetite include encouraging oral hygiene before a meal.

Rationale 5: Interventions to improve a clients appetite include providing medication for pain or other symptoms before a meal, and not after a meal.

Global Rationale: Page Reference:1281

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Discuss nursing interventions to treat clients with nutritional problems.

Question 33

Type: SEQ

A clients nasogastric tube has been discontinued, and needs to be removed. Place in order the steps the nurse will perform to remove this tube.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Place the tube in a plastic bag.

Choice 2. Ask the client to take a deep breath and to hold it.

Choice 3. Smoothly withdraw the tube.

Choice 4. Pinch the tube with the gloved hand.

Choice 5. Observe the intactness of the tube.

Choice 6. Apply clean gloves.

Correct Answer: 6,2,4,3,1,5

Rationale 1: When removing a nasogastric tube, the nurse should: 1) apply clean gloves; 2) ask the client to take a deep breath and to hold it; 3) pinch the tube with the gloved hand; 4) smoothly withdraw the tube; 5) place the tube in a plastic bag; and 6) observe the intactness of the tube.

Rationale 2: When removing a nasogastric tube, the nurse should: 1) apply clean gloves; 2) ask the client to take a deep breath and to hold it; 3) pinch the tube with the gloved hand; 4) smoothly withdraw the tube; 5) place the tube in a plastic bag; and 6) observe the intactness of the tube.

Rationale 3: When removing a nasogastric tube, the nurse should: 1) apply clean gloves; 2) ask the client to take a deep breath and to hold it; 3) pinch the tube with the gloved hand; 4) smoothly withdraw the tube; 5) place the tube in a plastic bag; and 6) observe the intactness of the tube.

Rationale 4: When removing a nasogastric tube, the nurse should: 1) apply clean gloves; 2) ask the client to take a deep breath and to hold it; 3) pinch the tube with the gloved hand; 4) smoothly withdraw the tube; 5) place the tube in a plastic bag; and 6) observe the intactness of the tube.

Rationale 5: When removing a nasogastric tube, the nurse should: 1) apply clean gloves; 2) ask the client to take a deep breath and to hold it; 3) pinch the tube with the gloved hand; 4) smoothly withdraw the tube; 5) place the tube in a plastic bag; and 6) observe the intactness of the tube.

Rationale 6: When removing a nasogastric tube, the nurse should: 1) apply clean gloves; 2) ask the client to take a deep breath and to hold it; 3) pinch the tube with the gloved hand; 4) smoothly withdraw the tube; 5) place the tube in a plastic bag; and 6) observe the intactness of the tube.

Global Rationale: Page Reference:1287

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Verbalize the steps used in:
a. Inserting a nasogastric tube.

Question 34

Type: MCSA

The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?

1. Assess tube placement.

2. Measure vital signs.

3. Assist the client to a prone position.

4. Lower the head of the bed.

Correct Answer: 1

Rationale 1: Prior to administering a feeding through a gastrostomy tube, the nurse should assess for tube placement.

Rationale 2: The clients vital signs do not need to be assessed prior to receiving a feeding through a gastrostomy tube.

Rationale 3: The client should be in the sitting or the Fowlers position.

Rationale 4: The head of the bed should be elevated at least 30 degrees.

Global Rationale: Page Reference:1291

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Verbalize the steps used in:
d. Administering a gastrostomy or jejunostomy tube feeding.

Question 35

Type: MCMA

The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure?

Standard Text: Select all that apply.

1. Name of physician prescribing the feedings.

2. Solution provided.

3. Amount of fluid.

4. Duration of the feeding.

5. Client tolerance of the feeding.

Correct Answer: 2,3,4,5

Rationale 1: The nurse does not need to document the name of the physician who prescribed the feedings.

Rationale 2: When documenting after a tube feeding, the nurse should document the solution provided.

Rationale 3: When documenting after a tube feeding, the nurse should document the amount of fluid provided.

Rationale 4: When documenting after a tube feeding, the nurse should document the duration of the feeding.

Rationale 5: When documenting after a tube feeding, the nurse should document the clients tolerance of the feeding.

Global Rationale: Page Reference:1293

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Verbalize the steps used in:
c. Administering a tube feeding.
13 Demonstrate appropriate documentation and reporting of nutritional therapy.

Question 36

Type: MCSA

A client receives several tube feedings each day. After documenting the clients tolerance of the feedings and assessments in the medical record, the nurse should also document the amount of feeding provided on the:

1. Graphic sheet.

2. Dietary consultation notes.

3. Vital signs record.

4. Intake and output record.

Correct Answer: 4

Rationale 1: Fluid intake for each feeding is not entered on the graphic sheet. The amount of fluid for a 24-hour period would be documented on this sheet.

Rationale 2: Fluid intake for tube feedings is not documented in the dietary consultation notes.

Rationale 3: Fluid intake for tube feedings is not documented on the vital signs record.

Rationale 4: The amount of fluid as feeding provided to the client should be recorded on the intake and output record.

Global Rationale: Page Reference: 1293

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13 Demonstrate appropriate documentation and reporting of nutritional therapy.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

Leave a Reply