1
The parents of a 7-month-old child have started offering solid foods to their baby. The baby has enjoyed and tolerated rice cereal, applesauce, and other fruits. Which food should the nurse recommend to be introduced next?
1. Strained beef
2. Green beans
3. Squash
4. Strained chicken
Answer: 3
Explanation: 3. As the baby develops, foods are offered in the sequence in which they are generally best tolerated. Most experts recommend introducing cereals, fruits, yellow vegetables (e.g., squash), green vegetables (e.g., green beans), and then meats.
Page Ref: 1135
What nursing diagnosis is the most important for the nurse to include in the care plan of a client who has just been started on total parenteral nutrition (TPN) therapy?
1. Risk for Infection
2. Imbalanced Nutrition: Less Than Body Requirements
3. Activity Intolerance
4. Fluid Volume Deficit
Answer: 1
Explanation: 1. TPN is delivered via a venous catheter and is very high in glucose. There is a very high risk for infection.
Page Ref: 1169
A client's nasogastric tube has been discontinued and needs to be removed. Place in order the steps the nurse will perform to remove this tube.
1. Place the tube in a plastic bag.
2. Ask the client to take a deep breath and to hold it.
3. Smoothly withdraw the tube.
4. Pinch the tube with the gloved hand.
5. Observe the intactness of the tube.
6. Apply clean gloves.
Answer: 6, 2, 4, 3, 1, 5
Explanation: When removing a nasogastric tube, the nurse should: (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube.
Page Ref: 1169
While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Answer: 1
Explanation: 1. Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.
Page Ref: 159
A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client?
1. Pain due to unknown factors
2. Pain related to unknown etiology
3. Pain caused by psychosomatic condition
4. Pain manifested by client's report
Answer: 2
Explanation: 2. The second part of the nursing diagnosis statement is the etiology (E)—the factors contributing to or probable causes–and should be joined to the first part, the problem (P), by the words "related to" rather than "due to." The phrase "related to" implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident.
Page Ref: 182
A client who has undergone a gastrointestinal surgery is permitted to have a clear liquid diet on the second postoperative day. Which fluid should the nurse order from the diet kitchen for this client?
1. Apricot nectar
2. Cranberry juice
3. Chicken broth
4. Cherry ice pop
Answer: 3
Explanation: 3. Chicken broth is the only liquid listed that is clear and not red.
Page Ref: 1154
A client reports that an adolescent family member has started a vegan diet. Which additions to meals should the nurse recommend to help ensure that the adolescent does not become deficient in calcium? Select all that apply.
1. Tofu
2. Soybeans
3. Brewer's yeast
4. Raisins
5. Okra
Answer: 1, 2, 4
Explanation: 1. Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet tofu (soybean curd) fortified with calcium.
2. Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet soybean milk.
4. Raisins are a good source of iron.
Page Ref: 1144
The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?
1. Assess tube placement.
2. Measure vital signs.
3. Assist the client to a prone position.
4. Lower the head of the bed.
Answer: 1
Explanation: 1. Prior to administering a feeding through a gastrostomy tube, the nurse should assess for tube placement.
Page Ref: 1166
During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says "leave me alone." Which subjective data should the nurse document?
1. Restlessness
2. "Leave me alone"
3. Not talkative
4. Pale and diaphoretic
Answer: 2
Explanation: 2. Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client's sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations.
Page Ref: 160
A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client?
1. Altered oral mucous membranes, related to dry mouth
2. Activity intolerance, related to oxygen supply imbalance
3. Knowledge deficit, related to medication regimen
4. Ineffective airway clearance, related to increased secretions
Answer: 4
Explanation: 4. Prioritizing care must begin with the basic needs, in this case, the airway.
Page Ref: 185
Remember the ABC's
The nurse is preparing to insert a nasogastric tube into a client. In what order will the nurse conduct the following steps?
1. Ask the client to tilt the head forward.
2. Insert the tube with its natural curve toward the client.
3. Ask the client to hyperextend the neck.
4. Have the client swallow a small amount of liquid.
5. Employ a slight twisting motion on the tube.
Answer: 2, 3, 5, 1, 4
Explanation: 1. At this time, have the client tilt the head forward to facilitate passage of the tube into the posterior pharynx and esophagus.
2. The tube should first be inserted with its natural curve toward the client.
3. At this time, having the client hyperextend the neck will reduce the curvature of the nasopharyngeal junction.
4. The client should then be asked to swallow to move the epiglottis over the opening of the larynx, directing the tube toward the esophagus.
5. A slight twisting motion may help pass the tube into the nasopharynx.
Page Ref: 1157
The nurse is instructing a client on foods that are considered complete proteins. What will the nurse include in these instructions? Select all that apply.
1. Meat
2. Gelatin
3. Eggs
4. Chicken
5. Fish
Answer: 1, 3, 4, 5
Explanation: 1. Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including meats, are complete proteins.
3. Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including eggs, are complete proteins.
4. Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including poultry, are complete proteins.
5. Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including fish, are complete proteins.
Page Ref: 1128
The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? Select all that apply.
1. Name of physician prescribing the feedings
2. Solution provided
3. Amount of fluid
4. Duration of the feeding
5. Client tolerance of the feeding
Answer: 2, 3, 4, 5
Explanation: 2. When documenting after a tube feeding, the nurse should document the solution provided.
3. When documenting after a tube feeding, the nurse should document the amount of fluid provided.
4. When documenting after a tube feeding, the nurse should document the duration of the feeding.
5. When documenting after a tube feeding, the nurse should document the client's tolerance of the feeding.
Page Ref: 1165
The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Answer: 3
Explanation: 3. Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions.
Page Ref: 159
The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?
1. Activity intolerance
2. Weakness and debilitation
3. Reports of fatigue
4. Physical activity
Answer: 3
Explanation: 3. The defining characteristics are those reports given by the client, or the signs and symptoms.
Page Ref: 182
The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What should the nurse do first?
1. Place the client in high Fowler's position.
2. Turn off the tube feeding.
3. Assess the client's lung sounds.
4. Assess the client's bowel sounds.
Answer: 2
Explanation: 2. These findings indicate possible aspiration of the feeding. The priority action is to discontinue the feeding to eliminate the amount of material going into the client's lungs. This should be done before any further assessment or client position change is attempted. If it is discovered that there is no aspiration, the tube feeding can be restarted.
Page Ref: 1167
A client asks the nurse for help in selecting foods, as some are "good" and others are "bad." How should the nurse respond to the client? Select all that apply.
1. "Eat a wide variety of foods to furnish adequate nutrients."
2. "Avoid starchy foods."
3. "Limit foods with high-fructose corn syrup."
4. "Eat three meals a day to reduce calories."
5. "Eat moderately to maintain correct body weight."
Answer: 1, 5
Explanation: 1. Nurses should not use a "good food, bad food" approach, but rather should realize that variations of intake are acceptable under different circumstances. The only "universally" accepted guidelines are to eat a wide variety of foods to furnish adequate nutrients.
5. Nurses should not use a "good food, bad food" approach, but rather should realize that variations of intake are acceptable under different circumstances. The only "universally" accepted guidelines are to eat moderately to maintain correct body weight.
Page Ref: 1132
The nurse is concerned that an older client is at risk for aspiration. What feeding techniques should the nurse instruct the family to use once the client is discharged? Select all that apply.
1. Thicken all fluids.
2. Use the chin-tuck method.
3. Place the client in a seated position
4. Focus on food preferences.
5. Keep the head of the bed at a 30-degree angle.
Answer: 1, 2, 3, 4
Explanation: 1. Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include thickening fluids. Many older adults can swallow foods with thicker consistency more easily than thin liquids.
2. Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include using the chin-tuck method. Flexing the head toward the chest when swallowing decreases the risk of aspiration into the lungs.
3. Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include eating in a seated position.
4. Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include focusing on food preferences.
Page Ref: 1141
After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses?
1. The ones that the nurse is licensed to treat
2. The ones that address other health professionals' interventions
3. The ones that focus on the client's primary illness
4. The ones that have standardized care available
Answer: 1
Explanation: 1. The domain of nursing diagnoses includes only those health states that nurses are educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.
Page Ref: 177
The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Select all that apply.
1. The client has dry, cracked skin.
2. The client has one large and several smaller open, ulcerated areas on his right leg.
3. The client does not drive.
4. The client states that he does not use alcohol or drugs.
5. The client's clothes are soiled.
6. The client has obvious body odor.
Answer: 1, 2, 5, 6
Explanation: 1. Data that support this problem are clustered around the condition of the client's skin.
2. Data that support this problem are clustered around the condition of the client's skin.
5. Data that support this problem are clustered around the condition of the client's clothes.
6. Data that support this problem are clustered around the condition of the client's general appearance.
Page Ref: 179
As the nasogastric tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action?
1. Remove the tube and attempt reinsertion.
2. Give the client a few sips of water.
3. Use firm pressure to pass the tube through the glottis.
4. Have the client tilt the head back to open the passage.
Answer: 2
Explanation: 2. Swallowing ice or water may help calm the gag reflex and also facilitate the "swallowing" of the tube.
Page Ref: 1159
The nurse is planning interventions for a client to improve the appetite. What actions would be appropriate for this client? Select all that apply.
1. Select small portions.
2. Avoid unpleasant treatments immediately before or after a meal.
3. Ensure a clean environment free of unpleasant sights and odors.
4. Encourage oral hygiene before a meal.
5. Provide medication for pain or other symptoms after a meal.
Answer: 1, 2, 3, 4
Explanation: 1. Interventions to improve a client's appetite include selecting small portions.
2. Interventions to improve a client's appetite include avoiding unpleasant treatments immediately before or after a meal.
3. Interventions to improve a client's appetite include ensuring a clean environment that is free of unpleasant sights and odors.
4. Interventions to improve a client's appetite include encouraging oral hygiene before a meal.
Page Ref: 1155
The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Answer: 3
Explanation: 3. The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.
Page Ref: 155
The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label?
1. Must contain three components
2. Describes the health problem for which nursing therapy is given
3. Helps define medical diagnoses for nursing
4. Promotes a taxonomy of nursing
Answer: 4
Explanation: 4. The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given.
Page Ref: 176
The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems?
1. Mental status of the client
2. Chronic nature of the illness
3. Nursing care focus
4. Prognosis
Answer: 3
Explanation: 3. Nursing focus is an area that differs.
Page Ref: 176