nutrition
The nurse is caring for a malnourished patient. Which complication requires priority intervention?
A. Mild erythema over the sacrum
B. Increased appetite after supplements
C. BMI increasing from 17 to 18
D. Mild nausea after eating
Mild erythema over the sacrum
The nurse prepares to teach a postoperative patient about mobility and fall precautions. The patient reports severe pain (8/10) and appears visibly fatigued. What is the nurse’s best action?
A. Proceed with teaching because early mobility is essential
B. Provide written materials and ask the patient to read them later
C. Manage the patient’s pain first and reassess readiness to learn
D. Ask family members to participate while the patient rests
Manage the patient’s pain first and reassess readiness to learn
A client planning bariatric surgery needs further teaching when stating:
A. “I will need to follow dietary recommendations carefully.”
B. “I should watch for signs of complications at home.”
C. “I won’t need lifestyle changes after the surgery.”
D. “Pain management and drains may be part of recovery.”
“I won’t need lifestyle changes after the surgery.”
A malnourished patient has been receiving nutritional supplements and tube feedings for one week. Which finding indicates ineffective treatment?
A. Prealbumin rising from 8 mg/dL to 12 mg/dL
B. Weight gain of 0.5 kg in one week
C. Persistent negative nitrogen balance
D. Increased energy level and improved skin turgor
Persistent negative nitrogen balance
A patient with higher weight and comorbid hypertension begins weight-loss therapy. Which finding should the nurse recognize as requiring immediate intervention?
A. Patient reports mild nausea after GLP-1 injections
B. Patient has a BMI of 33 with central adiposity
C. Patient reports new right upper-quadrant abdominal pain
D. Patient is unable to meet a goal of 500 calorie reduction daily
Patient reports new right upper-quadrant abdominal pain
A nurse is assessing a patient for possible malnutrition. Which finding would the nurse expect?
A. Waist circumference of 38 inches
B. Muscle wasting and sunken cheeks
C. Elevated prealbumin level
D. Rapid weight gain with adipose deposits around the midsection
Muscle wasting and sunken cheeks
A patient is prescribed semaglutide for weight management. Which nursing consideration is most important?
A. Monitor for polycythemia
B. Assess for stimulant side effects
C. Monitor for signs of hypoglycemia
D. Administer the medication orally before meals
Monitor for signs of hypoglycemia
The nurse provides education for a patient with higher weight. Which statement demonstrates understanding?
A. “I will decrease my daily calories by 500–1000.”
B. “I should avoid all physical activity until weight decreases.”
C. “I will use semaglutide orally before meals.”
D. “I should focus only on medications for losing weight.”
“I will decrease my daily calories by 500–1000.”
A patient at the end of life is increasingly lethargic, has noisy gurgling respirations, and shows decreased ability to swallow. Which priority assessment should the nurse perform next?
A. Assess pain using the CPOT scale
B. Evaluate for fluid accumulation related to heart or kidney failure
C. Assess respiratory pattern and degree of dyspnea
D. Check for changes in vital signs indicating deterioration
Assess respiratory pattern and degree of dyspnea
A patient is being taught how to self-administer a new injectable medication. During the teaching session, the patient keeps asking unrelated questions, repeatedly checks their phone, and states, “I’ll figure it out once I’m home.”
Which cue indicates the greatest barrier to learning at this time?
A. The patient’s preference for reading instructions independently
B. The patient’s distractibility and lack of engagement
C. The complexity of the injection technique
D. The lack of family support during teaching
The patient’s distractibility and lack of engagement
The nurse reviews a patient’s lab values:
Prealbumin: 4 mg/dL
Albumin: 3.4 g/dL
Weight loss of 12% over 3 months
Based on this information, the nurse recognizes:
A. The patient has adequate protein intake
B. Severe protein malnutrition is likely
C. The albumin indicates a normal nutritional state
D. Weight changes are unrelated to nutrition
Severe protein malnutrition is likely
A patient receiving dronabinol asks why they are taking it. The nurse responds appropriately by stating:
A. “It decreases insulin resistance.”
B. “It works as an appetite stimulant.”
C. “It reduces calorie absorption.”
D. “It is used primarily to treat electrolyte imbalances.”
It works as an appetite stimulant.”
A patient with newly diagnosed hypertension is being discharged. Which teaching point should the nurse prioritize based on common medical teaching priorities?
A. The biochemical mechanism of blood pressure regulation
B. How to recognize signs that the condition is worsening
C. A detailed history of antihypertensive drug development
D. The role of the nurse in monitoring blood pressure trends
How to recognize signs that the condition is worsening
A terminally ill patient has the following findings:
Reports severe fatigue
Decreased level of consciousness
Poor oral intake
Increasing lower-extremity edema
What do these findings most likely indicate?
A. Disease-related anorexia with worsening heart/kidney failure
B. Adverse effects of opioid administration
C. Imminent respiratory arrest
D. Anxiety leading to decreased appetite and energy
Disease-related anorexia with worsening heart/kidney failure
After teaching a patient with low health literacy about using a mobility aid, which documentation best meets professional standards?
A. “Patient was taught about mobility aid.”
B. “Reviewed use of walker; patient nodded during explanation.”
C. “Taught use of walker using simple terminology; patient demonstrated proper use via teach-back; handout provided.”
D. “Attempted teaching but patient seemed tired; will try again tomorrow.”
“Taught use of walker using simple terminology; patient demonstrated proper use via teach-back; handout provided.”
A nurse is caring for a patient with a history of disordered eating. Which problems should the nurse anticipate? (Select all that apply.)
A. Hepatic steatosis
B. Coronary artery disease risk
C. Increased risk for chronic kidney disease
D. Increased insulin resistance
E. Elevated prealbumin levels
A. Hepatic steatosis
B. Coronary artery disease risk
C. Increased risk for chronic kidney disease
D. Increased insulin resistance
A patient at the end of life has loud respiratory secretions and family members appear distressed. Which medication should the nurse anticipate administering?
A. An opioid analgesic
B. A benzodiazepine for anxiety
C. An anticholinergic such as glycopyrrolate
D. An antiemetic prior to meals
An anticholinergic such as glycopyrrolate
A nurse is short on time and must prioritize teaching for a patient who is being discharged after an asthma exacerbation. Which statement BEST reflects application of the adult learning principle of relevance?
A. Teaching the anatomy of the pulmonary system to increase background knowledge
B. Reviewing all medication classes used for asthma treatment
C. Teaching how to recognize worsening symptoms and proper inhaler technique
D. Providing detailed research articles about asthma pathophysiology
Teaching how to recognize worsening symptoms and proper inhaler technique
A patient at the end of life has been receiving interventions for dyspnea and anxiety. Which finding best indicates the nursing plan of care has been effective?
A. Respirations remain rapid, but oxygen saturation increases
B. The patient appears relaxed, with eased breathing and fewer gasping episodes
C. Vital sign stability is maintained throughout the shift
D. The family reports feeling more hopeful about recovery
The patient appears relaxed, with eased breathing and fewer gasping episodes
A postoperative patient reports pain rated 8/10. Assessment findings include:
RR 10/min
SpO₂ 93% on room air
Drowsy but arousable
Recent IV morphine administration
What is the nurse’s priority action?
A. Administer additional opioid medication
B. Apply nonpharmacologic pain measures
C. Reassess pain using OPQRST
D. Monitor respiratory status closely
. Monitor respiratory status closely
A patient with a history of restrictive eating is admitted with the following labs:
Prealbumin: 7 mg/dL
K⁺: 2.9 mEq/L
Na⁺: 131 mEq/L
Albumin: 3.6 g/dL
The patient reports dizziness and fatigue. Which action should the nurse take first?
A. Notify the provider of the hypokalemia
B. Request a dietician consult for nutritional planning
C. Initiate calorie-dense oral supplements
D. Document albumin levels and reassess in 4 hours
Notify the provider of the hypokalemia
A patient receiving escalating doses of semaglutide for weight reduction reports new symptoms of shakiness, sweating, and confusion. Vitals:
HR 110
BP 102/64
Glucose: 62 mg/dL
Which action should the nurse take?
A. Hold the medication and provide a glucose source
B. Encourage the patient to increase activity levels
C. Continue therapy; symptoms will improve as the dose stabilizes
D. Give the next dose early to maintain GLP-1 levels
Hold the medication and provide a glucose source
A nurse teaches a patient with new mobility restrictions about using a walker and documents the following:
“Patient educated on walker use. Appeared to understand. Will follow up tomorrow.”
What is the MOST significant problem with this documentation?
A. It fails to specify the educational materials used
B. It reflects bias about the patient’s abilities
C. It does not include a description of the patient’s response or teach-back
D. It violates scope of practice by speculating about outcomes
It does not include a description of the patient’s response or teach-back
A severely malnourished patient presents with early redness over several bony prominences and reports decreased intake due to nausea. Which nursing intervention has the highest priority?
A. Provide antiemetic therapy before meals
B. Reposition the patient at least every 2 hours
C. Educate the patient on high-protein food sources
D. Schedule a mental health consult for disordered eating
Reposition the patient at least every 2 hours
Which finding indicates that aspiration prevention interventions have been effective?
A. The patient reports decreased nausea
B. Oxygen saturation remains stable during vomiting episodes
C. Antiemetics are administered on schedule
D. Intake equals output
Oxygen saturation remains stable during vomiting episodes