Nutrition
A nurse is assisting a visually impaired client with eating lunch. Which of the following actions is the most appropriate for the nurse to take?
A. Feed the client each bite to ensure safety
B. Cut up the food and mix it together to make it easier to eat
C. Explain the location of foods using the clock-face method D. Describing the texture and temperature of each food item
C. Explain the location of foods using the clock-face method
The clock-face method allows a visually impaired client to conceptualize the location of food on their plate (e.g., "Your chicken is at 6 o’clock"). This promotes independence and dignity.
A nurse assesses a client with a nasal cannula and notices redness and indentation behind the ears. What is the nurse's priority action?
A. Reposition the nasal cannula tubing and apply protective padding
B. Remove the oxygen device immediately and notify the provider
C. Clean the area with alcohol and leave the skin open to air
D. Switch the client to a non-rebreather mask
A. Reposition the nasal cannula tubing and apply protective padding
Repositioning and applying padding (e.g., gauze or foam) can reduce pressure and prevent further skin damage.
A nurse is administering prescribed ophthalmic drops to a client. Which of the following actions by the nurse helps prevent systemic absorption of the medication?
A. Instruct the client to blink several times after each drop
B. Apply gentle pressure to the inner canthus of the eye for 30 to 60 seconds
C. Place the drops directly onto the cornea
D. Ask the client to look upward and rapidly move their eyes side to side
B: Apply gentle pressure to the inner canthus of the eye for 30 to 60 seconds
This technique, known as nasolacrimal occlusion, prevents the medication from draining into the nasolacrimal duct, where it could be systemically absorbed through the nasal mucosa and enter the bloodstream. This is especially important for medications like beta blockers (e.g., timolol), which can affect heart rate and blood pressure.
A client reports difficulty falling asleep, frequent nighttime awakenings, and feeling tired during the day for the past 3 months. Which additional question is most important for the nurse to ask to help diagnose insomnia?
A. “Do you have any history of substance use or caffeine intake?”
B. “Have you traveled recently across multiple time zones?”
C. “Do you take any medications that interfere with sleep?”
D. “Have you experienced daytime sleepiness or impairment?”
D. “Have you experienced daytime sleepiness or impairment?”
Daytime impairment or sleepiness is a key diagnostic criterion for insomnia disorder. Substance use and medications are relevant but secondary to establishing the impact on functioning. Travel across time zones relates more to jet lag.
Which lab value is most useful in assessing a client’s recent nutritional status?
A. Serum albumin
B. Hemoglobin
C. Prealbumin
D. Hematocrit
C. Prealbumin
Prealbumin has a short half-life (~2 days), making it a sensitive marker for acute changes in nutritional status.
Albumin reflects long-term nutrition (3-week half-life).
Hemoglobin and hematocrit assess anemia, not general nutrition.
A nurse is caring for a client with iron-deficiency anemia who speaks limited English. Which of the following is the most appropriate initial action to ensure effective nutrition education?
A. Ask a bilingual staff member from another department to translate
B. Use a certified medical interpreter to assist with teaching
C. Use hand gestures and pictures to explain the information
D. Ask the client’s family member to interpret during the teaching session
B. Use a certified medical interpreter to assist with teaching
Certified medical interpreters ensure accurate and ethical communication, particularly in sensitive and health-related contexts.
A nurse is caring for a postoperative client receiving 2 L/min of oxygen via nasal cannula. The nurse notes that the client is restless and picking at the bed sheets. What is the priority action?
A. Reorient the client to person, place, and time
B. Notify the provider and request antianxiety medication
C. Assess the client’s oxygen saturation level
D. Encourage the client to rest quietly
C. Assess the client’s oxygen saturation level
Restlessness, confusion, and agitation are early signs of hypoxia, particularly in clients at risk (e.g., postoperative, respiratory conditions). The priority action is to check oxygenation status via pulse oximetry, check to see if the prongs are functioning properly and in the nostrils, and if needed increase O2.
A nurse manager learns that several staff nurses on a unit have made repeated medication errors. What is the best initial action by the nurse manager?
A. Report all involved nurses to the state board of nursing
B. Schedule disciplinary meetings with each nurse
C. Conduct a root cause analysis of the medication errors
D. Increase supervision of medication administration
C. Conduct a root cause analysis of the medication errors
This is the best first step. It allows the nurse manager to identify underlying system or process issues (e.g., poor labeling, time pressures, distractions) and not just individual errors. The focus is on systems improvement and error prevention, not blame.
A client diagnosed with Restless Leg Syndrome tells the nurse they have difficulty falling asleep due to symptoms. What is the nurse’s most appropriate initial recommendation?
A. Take a sedative at bedtime
B. Perform stretching exercises before sleep
C. Avoid all daytime activity
D. Elevate the legs during the night
Correct Answer: B. Perform stretching exercises before sleep
Moderate exercise, leg stretches, and massage can help relieve RLS symptoms.
A nurse is teaching a client about the clear liquid diet. Which of the following foods and beverages are appropriate for this diet? (Select all that apply.)
A. Apple juice
B. Broth (clear)
C. Coffee with cream
D. Gelatin (without added fruit)
E. Ice pops without milk
F. Orange juice with pulp
Correct Answers: A, B, D, E
A. Apple juice – Clear juices without pulp are allowed because they are transparent liquids.
B. Broth (clear) – Clear broth (e.g., chicken or beef broth) is appropriate as it is a transparent liquid.
D. Gelatin (without added fruit) – Plain gelatin is clear and allowed; fruit pieces would make it unsuitable.
E. Ice pops without milk – Clear ice pops without milk or fruit bits are allowed.
Incorrect C. Coffee with cream – Cream makes the coffee cloudy, so it is not allowed on a strict clear liquid diet.
Incorrect F. Orange juice with pulp – Pulp makes the juice cloudy and solid, so it is not allowed.
A nurse is educating a client on the proper use of fat-soluble vitamin supplements. Which of the following statements by the client requires further teaching?
A. "I will avoid taking more than the recommended dose of vitamin A."
B. "I’ll take these vitamins with meals that contain fat to help with absorption."
C. "I understand that vitamins A, D, E, and K are fat-soluble."
D. "Because these vitamins are stored in fat, I can take large doses without harm."
D. "Because these vitamins are stored in fat, I can take large doses without harm."
Fat-soluble vitamins can accumulate in the body and lead to toxicity if taken in excess.
A client is being discharged home on oxygen via nasal cannula. Which of the following statements indicates a need for further teaching?
A. "I will clean my mouth and lips frequently to prevent dryness."
B. "I can use a humidifier with my oxygen if prescribed."
C. "It’s okay to use Vaseline in my nose if it feels dry."
D. "I will drink plenty of fluids throughout the day."
C. "It’s okay to use Vaseline in my nose if it feels dry."
Vaseline (petroleum jelly) is highly flammable and unsafe for use with oxygen.
A nurse is applying a transdermal patch to a client’s skin. Which action is most important to ensure proper medication absorption?
A. Apply the patch to a hairy, oily area to increase absorption
B. Rotate the application site with each new patch
C. Place the patch over a scar or tattoo to reduce irritation
D. Apply heat over the patch to speed medication release
B. Rotate the application site with each new patch
Rotating sites prevents skin irritation and allows better absorption. Hairy or oily areas reduce adhesion and absorption (A). Applying over scars or tattoos (C) can alter absorption. Applying heat (D) can increase absorption unpredictably and risk toxicity.
A nurse is assessing a hospitalized client for sleep deprivation. Which of the following findings should the nurse identify as possible effects of inadequate sleep? (Select all that apply.)
A. Impaired memory and concentration
B. Decreased sensitivity to pain
C. Mood swings or irritability
D. Delayed healing and immune suppression
E. Improved glucose regulation
Correct Answers: A, C, D
A. Impaired memory and concentration – Common effects of sleep deprivation; the brain needs rest to function optimally.
C. Mood swings or irritability – Lack of sleep alters mood and emotional regulation.
D. Delayed healing and immune suppression - Chronic sleep deprivation weakens the immune system and impairs tissue repair.
Incorrect B. Decreased sensitivity to pain – Sleep deprivation often leads to increased pain sensitivity.
Incorrect E. Improved glucose regulation – Sleep deprivation is associated with impaired glucose tolerance and insulin resistance.
A nurse is teaching a client about healthy sleep habits. Which of the following instructions should the nurse include in the teaching?
(Select all that apply.)
A. Go to bed and wake up at the same time every day
B. Avoid caffeine and nicotine in the hours before bedtime
C. Take a daytime nap of at least 2 hours to reduce fatigue
D. Engage in regular exercise at least 2 hours before bed
E. Keep the bedroom cool, quiet, and dark
F. Use the bed only for sleep and intimacy
G. Watch TV in bed to help relax before sleeping
Correct: A, B, D, E, F
A. Go to bed and wake up at the same time every day: A consistent sleep schedule helps regulate the circadian rhythm and improves overall sleep quality, even on weekends.
B. Avoid caffeine and nicotine in the hours before bedtime: Stimulants like caffeine and nicotine can interfere with the ability to fall asleep and stay asleep. These should be avoided 4–6 hours before bedtime.
D. Engage in regular exercise at least 2 hours before bed: Regular physical activity promotes better sleep, but it should be done earlier in the day, as late-night exercise can increase alertness and interfere with sleep onset.
E. Keep the bedroom cool, quiet, and dark: A calm and comfortable sleep environment supports deeper and uninterrupted sleep.
F. Use the bed only for sleep and intimacy: Limiting the bed to sleep and intimacy helps condition the brain to associate the bed with rest, improving sleep onset and maintenance.
A nurse is educating staff about nutritional screening tools. Which statement by a staff nurse indicates a need for further teaching?
A. "We can use the SGA tool to assess muscle wasting and weight change."
B. "BMI assesses weight and nutritional risks"
C. "The MNA only applies to patients in the ICU."
D. "Nutritional screening should be done within 24 hours of hospital admission."
C. "The MNA only applies to patients in the ICU."
The Mini Nutritional Assessment (MNA) is not limited to ICU patients—it’s designed for older adults, especially in community and long-term care settings.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen. Which oxygen delivery method is most appropriate?
A. Non-rebreather mask at 15 L/min
B. Simple face mask at 10 L/min
C. Venturi mask set to deliver 28% oxygen
D. Nasal cannula at 6 L/min
C. Venturi mask set to deliver 28% oxygen
Venturi masks provide precise FiO₂, which is important for clients with COPD who are at risk of losing their hypoxic respiratory drive if given too much oxygen.
The nurse is reviewing proper medication volumes for different injection sites. Which of the following statements are correct? (Select all that apply.)
A. The deltoid muscle can accommodate up to 1 mL of medication
B. The vastus lateralis site is appropriate for 1–2 mL in adults
C. The ventrogluteal site can be used for up to 5 mL in adults
D. Subcutaneous injections should not exceed 3 mL
E. Intradermal injections are typically limited to 0.1 mL
F. The dorsogluteal site is the safest for IM injections
Correct Answers: A, B, C, D, E
A. The deltoid muscle can accommodate up to 1 mL: This site is small and used for low-volume injections like vaccines.
B. The vastus lateralis site is appropriate for 1–2 mL in adults: This site is large and frequently used in infants and adults for moderate-volume IM injections.
C. The ventrogluteal site can be used for up to 5 mL in adults: It's the safest large-volume IM site due to minimal nerve/vessel risk.
D. Subcutaneous injections should not exceed 3 mL: SubQ injections should NOT exceed 1.5 mL.
E. Intradermal injections are typically limited to 0.1 mL: Intradermal (e.g., TB tests) use a very small volume, usually 0.1 mL or less.
Which of the following findings are associated with REM sleep? (Select all that apply.)
A. Vivid dreaming
B. Muscle tone is increased
C. Rapid eye movements occur
D. Heart rate and respiratory rate may become irregular
E. Deep, restorative physical rest
F. It typically begins immediately after falling asleep
Correct Answers: A, C, D
A. Vivid dreaming: The most vivid dreams occur during REM sleep, which plays a critical role in emotional and cognitive processing.
C. Rapid eye movements occur: As the name suggests, REM sleep is characterized by quick, jerky eye movements beneath closed eyelids.
D. Heart rate and respiratory rate may become irregular: Autonomic nervous system activity increases in REM sleep, leading to irregular heart rate and breathing patterns.
Incorrect: B. Muscle tone is increased_ During REM sleep, the body experiences muscle atonia (temporary paralysis of voluntary muscles), which prevents the person from acting out dreams.
Incorrect: E. Deep, restorative physical rest_Physical restoration primarily occurs during non-REM stage 3 (deep sleep), not REM. REM is more associated with mental and emotional restoration.
Incorrect: F. It typically begins immediately after falling asleep_ REM sleep occurs about 90 minutes after sleep onset and cycles throughout the night, increasing in duration with each cycle.
A nurse is providing dietary teaching to a client who has been prescribed a pureed diet due to swallowing difficulties. Which of the following foods are appropriate for this diet?
(Select all that apply.)
A. Mashed potatoes with gravy
B. Scrambled eggs
C. Peanut butter on toast
D. Smooth applesauce
E. Chicken salad sandwich
F. Blended oatmeal with milk G. Yogurt without fruit chunks
Correct Answers: A, D, F,
A. Mashed potatoes with gravy: Mashed potatoes are soft and can be pureed to a smooth consistency. Gravy adds moisture, making it easier to swallow and reducing aspiration risk.
D. Smooth applesauce: Applesauce is a naturally pureed food with a smooth texture, making it appropriate for clients with chewing or swallowing issues.
F. Blended oatmeal with milk: Oatmeal can be blended to a smooth, lump-free consistency and is commonly used on pureed diets. Adding milk increases caloric and protein intake.
G. Yogurt without fruit chunks: Plain or smooth yogurt is appropriate as long as it does not contain seeds, fruit pieces, or granola, which could pose a choking hazard.
Which of the following findings in a client receiving enteral nutrition via NGT requires immediate nursing action?
A. Crackles in lung bases
B. A pH reading of 4 on gastric aspirate
C. A gastric residual of 200 mL D. Reports of mild abdominal cramping during feeding
A. Crackles in lung bases
Crackles may indicate aspiration pneumonia, a serious complication of NGT feeding. Immediate action is required to stop the feeding and alert the provider.
A client is admitted with acute respiratory distress and has an SpO₂ of 84% on room air. Which oxygen device should the nurse apply first to rapidly improve oxygenation?
A. Nasal cannula at 2 L/min
B. Simple face mask at 5 L/min
C. Venturi mask at 24%
D. Non-rebreather mask at 15 L/min
D. Non-rebreather mask at 15 L/min
Rationale:
A non-rebreather mask delivers up to 95–100% FiO₂ and is appropriate for emergent or critically low oxygenation.
A nurse is caring for a client who incorporates Eastern medicine into their health practices. Which of the following statements made by the nurse demonstrate appropriate understanding of Eastern medicine principles? (Select all that apply.)
A. “Acupuncture is used to restore balance in energy flow.”
B. “Cupping therapy may leave circular bruises on the skin.”
C. “Eastern medicine focuses primarily on the germ theory of disease.”
D. “Yin and yang are central concepts in traditional Chinese medicine.”
E. “I will ask if you are using herbal remedies to prevent interactions.”
F. “Clients who use Eastern medicine typically reject all Western treatments.”
Correct Answers: A, B, D, E
A. “Acupuncture is used to restore balance in energy flow.”: Acupuncture is a key component of Traditional Chinese Medicine (TCM) and is believed to restore balance by stimulating specific energy points (meridians) to promote the flow of "Qi" (vital energy).
B. “Cupping therapy may leave circular bruises on the skin.: Cupping involves placing heated or suction-based cups on the skin to improve energy flow and blood circulation. It often results in painless, circular bruises, which are expected and not harmful.
D. “Yin and yang are central concepts in traditional Chinese medicine.”: The balance of yin and yang (opposing but complementary energies) is foundational to Eastern medicine. Illness is believed to arise from an imbalance of these forces.
E. “I will ask if you are using herbal remedies to prevent interactions.”: This shows safe and culturally sensitive practice. Many Eastern therapies include herbal treatments, which may interact with prescribed medications, and nurses must assess for these to prevent harm.
A nurse is caring for a hospitalized client who is known to sleepwalk. Which of the following interventions should the nurse implement to promote client safety?
(Select all that apply.)
A. Place the bed in the lowest position
B. Apply wrist restraints at night
C. Ensure the room is free of clutter
D. Keep the lights on all night
E. Use a bed alarm or motion sensor
F. Gently redirect the client back to bed if found sleepwalking
G. Keep the side rails up and locked at all times
Correct Answers: A, C, E, F
A. Place the bed in the lowest position: Lowering the bed reduces the risk of injury if the client gets out of bed unassisted or falls during sleepwalking.
C. Ensure the room is free of clutter: Keeping the floor clear of obstacles minimizes the risk of tripping or falling during episodes of sleepwalking.
E. Use a bed alarm or motion sensor: A bed alarm alerts staff if the client gets up, allowing for prompt intervention to guide the client safely.
F. Gently redirect the client back to bed if found sleepwalking: If a client is sleepwalking, the nurse should avoid startling them and gently guide them back to bed to maintain safety and minimize confusion.
A nurse is assessing the nutritional status of an older adult client. Which of the following are expected findings related to aging that can affect nutrition?
(Select all that apply.)
A. Decreased sense of taste and smell
B. Increased salivary production
C. Reduced ability to absorb vitamin B12
D. Slower gastric motility
E. Increased basal metabolic rate
F. Ill-fitting dentures
G. Increased thirst sensation
Correct Answers: A, C, D, F
A. Decreased sense of taste and smell: is a common age-related change and can lead to reduced appetite, decreased enjoyment of food, and poor nutritional intake.
C. Reduced ability to absorb vitamin B12: Older adults often produce less intrinsic factor and stomach acid, leading to decreased absorption of vitamin B12, which can cause anemia and neurologic symptoms.
D. Slower gastric motility: Gastric emptying and motility slow down with age, contributing to early satiety, constipation, and decreased appetite.
F. Ill-fitting dentures: Tooth loss and poor-fitting dentures are common and can interfere with chewing, which may reduce intake of nutrient-rich foods like fruits, vegetables, and meats.