Nutrition
The nurse is educating a patient who recently underwent bowel surgery about a low-residue diet. Which meal selection by the patient indicates understanding of this diet?
A) Bran cereal with strawberries.
B) White toast with scrambled eggs.
C) Ice cream with fresh raspberries.
D) Vegetable and bean soup.
B) White toast with scrambled eggs.
A nurse is reviewing the BMI results for several patients. Which patients should the nurse identify as having class II obesity?
A) BMI of 32
B) BMI of 36
C) BMI of 28
D) BMI of 18.5
B) BMI of 36
During the early phase of starvation, which energy source does the body primarily rely on before fat stores are used?
A. Muscle protein
B. Glycogen stores
C. Ketone bodies
D. Vitamins
B) Glycogen stores
Which skin assessment finding is expected in older adults due to aging?
A. Increased subcutaneous fat around abdomen
B. Thin, fragile skin
C. Thick, elastic skin with good wound healing
D. Hyperpigmented patches that blanch easily
B) Thin, fragile skin
A patient with cardiovascular disease is prescribed a low-sodium, low-fat diet. Which food choice is most appropriate?
A. Grilled salmon with steamed broccoli
B. Grilled chicken with mashed potatoes
C. Cheeseburger with a side of Caesar salad
D. Creamy macaroni and cheese
A) Grilled salmon with steamed broccoli
A 26-year-old vegan patient c/o fatigue, and numbness in her extremities. Lab results indicate macrocytic anemia. Which nursing action is most appropriate.
A) Educate the patient to begin taking a B12 supplement daily.
B) Recommend consuming foods that are iron-dense with a glass of orange juice.
C) Advise the patient to begin eating dairy products.
D) Teach the patient that these are normal symptoms for vegans to experience.
A) Educate the patient to begin taking a B12 supplement daily.
A patient has a BMI of 37kg/m. Which additional findings would the nurse expect to see? (SATA)
A) Increased risk of hypertension & type 2 diabetes
B) Indication for bariatric surgery regardless of comorbidities
C) Waist circumference greater than 35 in (women)
D) Require for immediate hospitalization for medical stabilization
A) Increased risk of hypertension & type 2 diabetes
C) Waist circumference greater than 35 in (women)
A patient recently started on tube feedings. Which findings should concern the nurse? (SATA)
A. Hypophosphatemia
B. Bradycardia
C. Hyperkalemia
D. Elevated albumin
A) Hypophosphatemia
B) Bradycardia
C) Hyperkalemia
A 72-year-old patient with heart failure presents with thin, shiny skin on the lower legs and non-blanching areas over the sacrum. The nurse knows that these findings suggest:
A. Normal aging changes from cormorbidities
B. Early-stage pressure injury with possible compromised perfusion
C. Allergic dermatitis
D. Stage II pressure ulcer
B) Early-stage pressure injury with possible compromised perfusion
Which intervention is a priority for a hospitalized patient at risk for malnutrition?
A. Provide oral hygiene before meals
B. Offer standard hospital trays
C. Avoid snacks between meals
D. Monitor vital signs hourly
A) Provide oral hygiene before meals
Oral care enhances appetite and intake; standard trays or avoiding snacks may reduce nutrition. Vital signs are important but not directly related to intake
An elderly patient with a decreased appetite and recent weight loss. Which nursing interventions will help patients with oral intake (SATA)
A) Offer small, frequent meals with high nutrient density
B) Encourage family to bring in culturally preferred foods
C) Schedule meals immediately after physical therapy
D) Provide adaptive utensils and ensure dentures fit properly
A) Offer small, frequent meals with high nutrient density
B) Encourage family to bring in culturally preferred foods
When conducting a health history for an obese patient, the nurse should include which assessment components? (SATA)
A. Usual daily food intake and eating patterns
B. History of weight gain and loss attempts
C. Current medications and their side effects
D. Personal views about body image
E. Family history of obesity or metabolic disorders
F. Color of stool and urine
A. Usual daily food intake and eating patterns
B. History of weight gain and loss attempts
C. Current medications and their side effects
D. Personal views about body image
E. Family history of obesity or metabolic disorders
A nurse is caring for a patient with severe protein-calorie malnutrition. Which laboratory result is the most important for the nurse to monitor to evaluate the patient’s nutritional status?
A. Serum calcium
B. Serum albumin
C. Serum sodium
D. Blood urea nitrogen (BUN)
B) Serum albumin
Which diet is most appropriate to promote healing of a stage III pressure ulcer?
A. High-calorie, high-protein with vitamin C and zinc
B. Low-fat, low-calorie with high fiber
C. Clear liquids
D. High-protein, high-carbohydrate diet
A) High-calorie, high-protein with vitamin C and zinc
A nurse is assisting a patient with hemiplegia during mealtime. Which action is most appropriate?
A. Feed the patient as quickly as possible
B. Allow the patient to self-feed using adaptive utensils
C. Tell the patient to use the unaffected hand only
D. Place food on the non-affected side of the plate
B) Allow the patient to self-feed using adaptive utensils
An elderly patient with osteoporosis states “I usually eat alone, so I just eat a piece of toast with my coffee most mornings”. Which nursing action is most appropriate? (select all that apply).
A) Advise the patient to take a multivitamin instead of meals.
B) Remind the patient to drink coffee to stay hydrated.
C) Recommend the patient take a calcium supplement daily.
D) Suggest joining a senior meal program at the local community center.
C) Recommend the patient take a calcium supplement daily.
D) Suggest joining a senior meal program at the local community center.
The nurse is reviewing a patient’s medical history. Which findings place the patient at greatest risk for complications related to obesity? (SATA)
A. Fasting blood glucose of 180 mg/dL
B. LDL cholesterol 180 mg/dL
C. Resting heart rate of 60 bpm
D. Blood pressure 150/95 mmHg
E. Reports of daytime sleepiness and snoring
F. Chronic diarrhea
A. Fasting blood glucose of 180 mg/dL
B. LDL cholesterol 180 mg/dL
D. Blood pressure 150/95 mmHg
E. Reports of daytime sleepiness and snoring
A nurse assesses a patient with brittle hair and delayed wound healing. Which additional finding would support a diagnosis of malnutrition? (select all that apply)
A) pale conjunctive
B) smooth, beefy red tongue
C) dry flaky skin
D) firm pink nail beds
E) muscle wasting in upper extremities
F) shiny hair with intact scalp
A) pale conjunctive
C) dry flaky skin
E) muscle wasting in upper extremities
Which findings indicate early pressure injury in patients with darker skin tones? (SATA)
A. Purple or blue discoloration over bony prominences
B. Warmth, edema, or induration over the sacrum
C. Non-blanchable redness clearly visible
D. Pale gray or ashen appearance
A) Purple or blue discoloration over bony prominences
B) Warmth, edema, or induration over the sacrum
C) Pale gray or ashen appearance
A nurse is reviewing dietary options with several patients prescribed different therapeutic diets. Which foods are appropriate for the following diets? (SATA)
A. Low-residue → canned peaches (without skin)
B. High-calorie, high-protein → full-fat Greek yogurt with honey
C. Clear-liquid → strained vegetable soup
D. Mechanical soft → scrambled eggs
A. Low-residue → canned peaches (without skin)
B) High-calorie, high-protein → full-fat Greek yogurt with honey
D) Mechanical soft → scrambled eggs
The nurse is caring for a patient recovering from oral surgery who has been prescribed a mechanical soft diet. Which foods should be included in the meal plan? (SATA)
A. Scrambled eggs
B. Mashed potatoes
C. Toasted nuts
D. Ground turkey with gravy
E. Steamed broccoli florets
F. Cottage cheese
A) Scrambled eggs
B) Mashed potatoes
D) Ground turkey with gravy
F) Cottage cheese
A nurse is caring for an obese patient hospitalized with pneumonia. Which nursing considerations are most important to reduce complications? Select all that apply.
A. Assess for breathing patterns due to decreased chest expansion.
B. Encourage frequent repositioning
C. Restrict fluids to prevent edema.
D. Use incentive spirometry and ambulation
E. Monitor for venous thromboembolism
F. Delay activity until full weight loss is achieved.
A. Assess for breathing patterns due to decreased chest expansion.
B. Encourage frequent repositioning
D. Use incentive spirometry and ambulation
E. Monitor for venous thromboembolism
A patient with severe malnutrition begins enteral feeding. Which nursing action is the highest priority?
A. Weigh the patient
B. Assess lung sounds
C. Flush the tube once per day after each administration
D. Encourage ambulation after feeding.
B) Assess lung sounds
Which findings in patients of different ages indicate abnormal skin integrity? (SATA)
A. Thin, fragile skin with delayed healing in an older adult
B. Mottled extremities in a neonate
C. Ecchymosis in a toddler without trauma
D. Cherry angiomas in a 70-year-old adult
E. Peeling of the palms and soles in a 2-week-old neonate
A) Thin, fragile skin with delayed healing in an older adult
C) Ecchymosis in a toddler without trauma
Thin skin is normal in older adults but delayed healing is a problem; ecchymosis without trauma indicates possible abuse or bleeding disorder. Mottling and peeling are normal neonatal findings; cherry angiomas are benign.
The nurse is preparing to perform a blood glucose monitoring test on a patient. Place the steps for performing the procedure in the correct sequence.
1. Press button on meter to confirm match codes.
2. Bringing meter to test strip, allow blood drop to wick onto test strip.
3. Instruct patient to perform hand hygiene with soap and water.
4. Clean patient finger with antiseptic swab.
5. Interpret results and document.
6. Check code on test strip vial.
7. Holding lancet to finger, press release button on machine.
8. Perform hand hygiene and put on clean gloves.
3, 6, 1, 8, 4, 7, 2, 5