Ch. 37 Nutrition
The nurse is teaching a client about the basic classes of nutrients needed for health. Which statement by the client indicates correct understanding of the major nutrient classes?
a)“Vitamins provide the body with energy for daily activities.”
b)“Carbohydrates, proteins, and fats are considered macronutrients.”
c)“Minerals are the primary source of calories for the body.”
d)“Water is not considered an essential nutrient because it has no calories.”
b)“Carbohydrates, proteins, and fats are considered macronutrients.”
Macronutrients include carbohydrates, proteins, and fats, which provide energy and are needed in larger amounts
A nurse is caring for a postoperative client who reports, “My pain is worse when I take a deep breath.” Which assessment finding best reflects a specific element of the client’s pain experience that should guide the nurse’s immediate intervention?
a) The client rates pain as 8 on a 0-to-10 scale when coughing.
b) The client's temperature is 99.1°F (37.3°C).
c)The client states that a sibling had poor pain control post-surgery.
d)The client's surgical dressing is dry and intact.
a) The client rates pain as 8 on a 0-to-10 scale when coughing.
Pain intensity and aggravating activity are specific components of a pain assessment and help the nurse plan interventions such as splinting, premedication before coughing and deep breathing, and reassessment.
A confused patient attempts to climb out of bed. What is the nurse's priority intervention?
a)Apply restraints immediately
b)Increase environmental safety and use the least restrictive interventions
c)Administer a sedative
d)Raise all four side rails
b)Increase environmental safety and use the least restrictive interventions
Which structure is the primary site of gas exchange?
a)Bronchioles
b)Trachea
c)Alveoli
d)Pleura
c)Alveoli
What would be considered a normal pH result for blood?
a)7.55
b)7.25
c)7.40
d)7.30
c)7.40
Normal range is 7.35-7.45
A nurse is preparing to administer a bolus feeding through a client’s nasogastric (NG) tube. Which action should the nurse perform first to ensure safe administration of the enteral nutrition?
a) Flush the NG tube with 30 mL of sterile water
b)Place the client in a semi-Fowler’s position
c)Verify tube placement according to facility policy
d)Warm the formula to room temperature before administration
c) Verify tube placement according to facility policy
Before administering enteral nutrition, the nurse must verify tube placement to prevent complications such as aspiration from feeding into the lungs.
A client admitted with abdominal pain is guarding the right lower quadrant and rates pain as 7 on a 0-to-10 scale. Which nurse action best demonstrates a complete pain assessment?
a) Ask about onset, location, quality, intensity, pattern, aggravating and relieving factors, associated symptoms, and perform focused abdominal assessment.
b)Document the pain score and administer medication without additional questions to avoid delaying care.
c)Ask the provider to assess the client because guarding indicates a medical diagnosis.
d)Compare the client’s report with vital signs and document pain only if the vital signs are abnormal.
a) Ask about onset, location, quality, intensity, pattern, aggravating and relieving factors, associated symptoms, and perform focused abdominal assessment.
Why is Root Cause Analysis (RCA) performed after a serious safety event?
a)To discipline staff
b)To identify system problems and prevent recurrence
c)To determine financial responsibility
d)To update patient billing
b)To identify system problems and prevent recurrence
Which oxygen device delivers the highest oxygen concentration?
a) Nasal cannula
b) Simple face mask
c) Venturi mask
d) Non-rebreather mask
d) Non-rebreather mask
Rationale: A non-rebreather mask can deliver approximately 80–95% oxygen.
Which body fluid compartment contains approximately 70% of total body water?
a)Extracellular fluid (ECF)
b)Interstitial fluid
c)Intracellular fluid (ICF)
d)Intravascular fluid
c)Intracellular fluid (ICF)
About 70% of the body's total water is inside cells, making the intracellular fluid (ICF) the largest body fluid compartment. The remaining water is in the extracellular fluid (ECF), which includes the interstitial fluid and intravascular (plasma) fluid.
A nurse is developing a care plan for a client who is at risk for impaired nutritional status. The client has experienced a significant unintentional weight loss over the past month and reports decreased appetite. Which nursing intervention should the nurse include as a part of the care plan?
a)Encourage the client to consume three large meals daily
b)Monitor daily weight and document percentage of meals consumed
c)Restrict fluids before meals to increase food intake
d)Provide a high-protein diet without assessing food preferences
b)Monitor daily weight and document percentage of meals consumed
Monitoring weight trends and dietary intake provides objective data to evaluate the client’s nutritional status and determine whether interventions are effective. Accurate assessment is the first step in the nursing process before implementing additional interventions.
A client being discharged after hip surgery says, “I’m afraid to take pain medicine at home, but I also want to walk safely.” Which nurse response best empowers the client to direct the pain management plan?
a)“Take the medication only when the pain becomes unbearable.”
b)“Let’s review your pain goal, medication schedule, side effects to report, safe use, and nonmedicine strategies you can use before activity.”
c)“You should not worry about side effects if the medication was prescribed. The provider would not prescribe any medication if it wasn't safe.”
d)“Avoid walking until you no longer need pain medication.”
b)
“Let’s review your pain goal, medication schedule, side effects to report, safe use, and nonmedicine strategies you can use before activity.”
Effective teaching supports self-management by clarifying goals, safe medication use, expected effects, adverse effects, timing before activity, nonpharmacologic methods, and when to seek help
Which assessment finding is most consistent with a concussion?
a)Bradycardia and hypertension only
b)Confusion, headache, and balance problems
c)Fever and neck stiffness
d)Chest pain and dyspnea
b)Confusion, headache, and balance problems
The medulla is primarily stimulated by an increase in:
a) Oxygen
b) Carbon dioxide
c) Calcium
d) Sodium
b) Carbon dioxide
Rationale: Increased carbon dioxide is the strongest stimulus for breathing.
A nurse is caring for an older adult client with a decreased sense of thirst. Which nursing action is most appropriate to help maintain adequate fluid balance?
a)Offer large amounts of fluid just before bedtime
b)Record intake only when the client requests fluids
c)Allow the client to self-regulate fluid intake
d)Offer fluids at regular intervals throughout the day
d)Offer fluids at regular intervals throughout the day
A new graduate nurse is caring for a client receiving total parenteral nutrition (TPN). Which action by the nurse requires intervention the by the supervising nurse?
a)Checking the client’s blood glucose level every 6 hours
b)Changing the TPN tubing according to facility policy
c)Assessing the catheter insertion site for redness and drainage
d)Choosing the peripheral line instead of central venous catheter
D. Choosing the peripheral line instead of central venous catheter
A central venous catheter is preferred for TPN because of its high osmolarity and peripheral irritation.
A client with a three-year history of diabetes reports burning pain and tingling in both feet that continues despite healed skin and no recent injury. Which nursing interpretation is most appropriate?
a)The pain is most consistent with acute nociceptive pain from tissue injury.
b)The pain is most consistent with chronic neuropathic pain related to nerve dysfunction.
c)The pain is expected and should not require reassessment if vital signs are stable.
d)The pain indicates opioid tolerance and should be managed only by increasing opioid dosage.
b) The pain is most consistent with chronic neuropathic pain related to nerve dysfunction.
Burning, tingling, persistent pain associated with diabetes is characteristic of chronic neuropathic pain, whereas acute nociceptive pain is typically linked to recent tissue injury and expected healing patterns (Taylor et al., 2023).
A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to which of the following substances?
a)Experimentation with drugs and inhalants
b)The ingestion of substances in the home that contain lead
c)Malfunction of carbon monoxide monitor in the home
d)Exposure to toxic fumes in the home
a)Experimentation with drugs and inhalants
Which abnormal lung sound is commonly heard in pneumonia?
a) Bronchial sounds
b) Crackles
c) Pleural friction rub
d) Stridor
b) Crackles
Rationale: Crackles occur when air moves through fluid-filled alveoli, commonly seen with pneumonia.
A nurse is teaching a client about osmosis. Which statement by the client indicates correct understanding?
a)“Osmosis moves water from a less concentrated solution to a more concentrated solution.”
b)“Osmosis requires energy from ATP to move water.”
c)“Osmosis occurs only in the bloodstream.”
d)“Osmosis moves solutes from a low concentration to a high concentration.”
a)“Osmosis moves water from a less concentrated solution to a more concentrated solution.”
A nurse is caring for a client who has difficulty swallowing after a stroke. The client has lost 8 pounds in 2 weeks, has a low serum albumin level, and consumes less than 25% of meals. Which nursing diagnosis is the priority for the nurse to include in the care plan?
a) Imbalanced nutrition: less than body requirements related to difficulty swallowing
b) Altered body image related to stroke and significant weight loss
c) Activity intolerance related to decreased nutritional intake and weight loss
d) Deficient knowledge related to lack of understanding of dietary requirements
a) Imbalanced nutrition: less than body requirements related to difficulty swallowing
SeqAnswer ChoiceCorrectLock
A hospitalized client with sickle cell disease continues to report severe pain one hour after receiving prescribed analgesia. Which action best demonstrates interprofessional collaboration?
a)Document that the medication was ineffective and wait until the next scheduled dose.
b)Tell the client that the pain should be improved because medication was given. Provide the call light and make sure side rails are up.
c)Notify the provider with reassessment data and collaborate with pharmacy, pain management, and the client to revise the regimen.
d)Reduce the dose because continued pain suggests the client may be seeking medication.
c) Notify the provider with reassessment data and collaborate with pharmacy, pain management, and the client to revise the regimen.
Which developmental group is at the greatest risk for poisoning and asphyxiation?
a)School-age children
b)Toddler and preschooler
c)Adolescent
d)Older adult
b)Toddler and preschooler
p.839
Oxygen moves from the alveoli into the pulmonary capillaries because:
a) Oxygen concentration is higher in the alveoli.
b) Oxygen concentration is higher in the blood.
c) Carbon dioxide pushes oxygen into the blood.
d) The heart pumps oxygen into the capillaries.
a) Oxygen concentration is higher in the alveoli.
Oxygen diffuses from an area of higher partial pressure (alveoli) to lower partial pressure (blood).
The nurse notices that a client's intravenous site is swollen, cool to touch, and the infusion has slowed, but there is no redness or pain. What complication is most likely occurring?
a)Phlebitis
b)Extravasation
c)Thrombophlebitis
d)Infiltration
d)Infiltration
Regularly assess venous access sites to detect common complications of IV therapy including infiltration (inadvertent leakage of nonvesicant [agent capable of causing tissue damage] IV solution into surrounding tissue), extravasation (inadvertent leakage of vesicant IV solution into surrounding tissue), phlebitis (inflammation of the wall of a vein), thrombophlebitis (blood clot in a vein, causing inflammation), and infection.