Nutrition
A client with chronic kidney disease asks about diet. The nurse questions this food choice (1 item)
What is bananas or orange juice, tomato soup or anything high in K+
The priority assessment for a client with dyspnea is this. (Two parts minimum please)
What is respiratory status and oxygenation? Airway and breathing are priority before less urgent data.
A nurse is unfamiliar with a medication due now. Identify the safest action before administration.
What is consult an approved current drug reference?
A client is difficult to awaken, has very relaxed muscles, and wakes confused. What stage of sleep is this indicative of?
What is NREM stage III sleep, Stage III is deep sleep; clients may awaken slowly and appear confused.
A nurse is teaching a postoperative client how to prevent lung complications. Which actions should the client perform? Select all that apply.
A. Use the incentive spirometer as instructed
B. Cough and deep breathe regularly
C. Stay flat in bed to rest the lungs
D. Ambulate as soon as allowed
E. Splint the incision when coughing
F. Avoid repositioning if it causes mild discomfort
What are A, B, D, and E? Incentive spirometry, coughing/deep breathing, early ambulation, and splinting the incision help prevent atelectasis and pneumonia. Staying flat and avoiding repositioning increase the risk for postoperative respiratory complications.
A client with heart failure and poor oral intake is prescribed a low-sodium diet. The nurse reviews the client’s lunch tray. Which item requires follow-up?
A. Grilled chicken breast
B. Fresh apple slices
C. Canned soup
D. Steamed carrots
What is canned soup, Canned soup is often high in sodium and can worsen fluid retention and cardiac workload in heart failure. Grilled chicken, fresh fruit, and steamed vegetables are generally better low-sodium choices.
A COPD client is short of breath but alert. What breathing technique should be taught, and why?
What is pursed-lip breathing? As it prolongs exhalation to blow off CO2, reduces air trapping, and improves ventilation.
What are 6 of the rights of medication administration?
What is right route, right pt, right reason, right education, right to refuse, right documentation etc etc
A hospitalized client takes naps all day, drinks coffee at 2100, and reports insomnia. Priority teachings?
What is avoid evening caffeine and limit daytime naps? Sleep hygiene includes reducing stimulants and preserving the sleep-wake cycle.
Which actions prevent med errors?
A) Two identifiers
B) barcode scanning
C) clarify unclear orders
D) document before giving
E) check allergies.
What are two identifiers, barcode scanning, clarify unclear orders, and check allergies?
A patient with weight loss needs a short-term nutrition marker. Identify the most useful lab.
What is prealbumin?
What are the flow rates of the following 3 oxygen devices Nasal Cannula, Simple Mask and NRB?
What is NC @ 1-6L
Simple Mask 5/6-10L
NRB 10-15L
Eye drops are administered into this area, avoiding direct contact with the cornea.
What is the lower conjunctival sac? This prevents injury and supports proper medication absorption.
A client reports loud snoring, daytime fatigue, and witnessed pauses in breathing. Confirmatory test?
What is polysomnography? A sleep study is used to diagnose obstructive sleep apnea.
Select all practices that reduce medication errors: two identifiers, clarify illegible orders, rely on room number, use current drug references, avoid trailing zeros, prepare all clients’ meds together.
What are two identifiers, clarify illegible orders, use current drug references, and avoid trailing zeros?
A client with pancreatitis related to alcohol use has been NPO for several days and is receiving parenteral nutrition. The Parenteral Nutrition bag runs empty before the next bag is available. The client becomes shaky, diaphoretic, and reports feeling “weak.” Which action should the nurse take first?
A. Hang 0.9% normal saline until the next PN bag arrives
B. Check the blood glucose and anticipate dextrose replacement
C. Restart oral clear liquids to prevent further calorie loss
D. Hold all fluids until the provider writes a new nutrition order
What is check the blood glucose and anticipate dextrose replacement?
Abrupt interruption of parenteral nutrition places the client at risk for hypoglycemia because the body has been receiving a continuous high-dextrose infusion. The pt has also been NPO for several days and is exhibiting signs of hypoglycemia
A client with COPD and pneumonia is receiving oxygen at 2 L/min by nasal cannula. The UAP reports the client is “more confused than usual.” Assessment shows RR 32/min, SpO₂ 86%, cyanotic lips, coarse crackles, and weak coughing. Which actions should the nurse take first?
What is first position the client upright and assess/clear the airway
A student says a missing route is okay because the medication was given IM last time. Identify the safety issue.
What is the medication order is incomplete and must be clarified before giving it? Medication rights require a complete current order, including route. Prior administration does not replace clarification.
A client takes sedatives, reports daytime drowsiness, and has frequent falls. Priority nursing concern?
What is injury risk related to sleep medication effects? Sedatives can impair balance, cognition, and safety, especially at night.
A client on IV antibiotics reports throat tightness and shortness of breath. Select all signs of possible anaphylaxis:
A) wheezing
B) severe hypotension
C) laryngeal edema,
D) mild nausea
E)severe dyspnea
F) cyanosis.
What are wheezing, severe hypotension, laryngeal edema, severe dyspnea, and cyanosis? These findings suggest airway compromise and systemic allergic reaction. Mild nausea alone is nonspecific and less concerning.
A client with chronic kidney disease and a stage 3 pressure injury is admitted with poor intake. The client has lost 10 lb in 1 month. Labs show albumin 2.6 g/dL, prealbumin below expected range, potassium 5.8 mEq/L, and glucose 118 mg/dL. The lunch tray contains
A) tomato soup
B) grilled chicken
C) white rice.
D) Low albumin and prealbumin
E) A banana
Which items should the nurse address first?
What is banana and tomato soup. The client has chronic kidney disease with hyperkalemia, so high-potassium foods such as bananas and tomato products should be addressed first. Low albumin, low prealbumin, weight loss, and the pressure injury indicate malnutrition and need for protein/calorie support, but the potassium level of 5.8 mEq/L is the more immediate safety concern. Grilled chicken may support wound healing, and white rice is generally appropriate for a renal diet.
Which findings require follow-up? SpO₂ 88%, RR 30, pink mucosa, cyanosis, new confusion. And name at least 3 interventions.
What are O2 of 88%, RR30, cyanosis and new confusion. Interventions can be bronchodilator medications, O2, sitting pt upright/high fowlers etc.
A 93-year-old's medication must be taken with food, but breakfast is delayed. The student leaves the medication at the bedside. Identify the error.
What is unsafe medication administration as the nurse must not leave medication unattended? The nurse must verify ingestion, timing, safety, and patient identity; leaving medications at bedside risks omission, overdose, or wrong timing.
A hospitalized older adult reports “not sleeping at all” for 3 nights. The client naps frequently during the day, drinks coffee with dinner @ 1800, rates pain 9/10, and the room is noisy overnight. Which nursing action is the priority?
What is assess and treat the client’s pain before bedtime? Pain is a physiologic barrier to sleep and should be addressed first. After pain is managed, the nurse can reduce caffeine, limit daytime naps, and modify the environment to promote sleep.
A client is receiving continuous tube feeding. Select all actions that reduce aspiration risk:
A) HOB 30-45 degrees,
B) verify tube placement,
C) place supine during feeding
D) monitor for coughing/crackles
E) pause feeding when flat
F) offer thin liquids
What are HOB 30-45 degrees, verify placement, monitor for coughing/crackles, and pause feeding when flat?