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1. An 82-year-old Latino patient with mild protein-calorie malnutrition shares a home with his spouse and adult daughter. When developing a teaching plan to improve the patient's nutrition, it will be most important for the nurse to obtain information about
a. food preferences of the spouse and adult child.
b. who shops for groceries and cooks.
c. the number of meals per day the patient eats.
d. foods that are culturally significant for the patient.

B
Rationale: The family member who shops for groceries and cooks will be in control of the patient's diet, so the nurse will need to ensure that this family member is involved in any teaching or discussion about the patient's nutritional needs. The other information will also be assessed and used but will not be useful in meeting the patient's nutritional needs unless nutritionally appropriate foods are purchased and prepared.

Cognitive Level: Application Text Reference: p. 951
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance

2. A patient who weighs 145 pounds (66 kg) asks the nurse how much protein should be included in the daily diet. The nurse recommends that the diet should include a minimum of _____ g protein.
a. 36
b. 53
c. 75
d. 98

B
Rationale: The recommended daily protein intake is 0.8 to 1 g/kg of body weight, which for this patient is 66 kg  0.8 g = 52.8 or 53 g/day for this patient.

Cognitive Level: Application Text Reference: p. 949
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

3. During assessment of a patient who is a vegan, the nurse observes for signs of nutritional deficiency. The most common nutritional deficiency related to a strict vegan diet would be manifested by
a. muscle wasting.
b. bleeding gums.
c. pallor and changes in sensation and movement of the extremities.
d. dry, scaly skin and cracked, painful oral mucous membranes.

C
Rationale: Cobalamin (vitamin B12) cannot be obtained in foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as anemia and peripheral neuropathy. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.

Cognitive Level: Application Text Reference: pp. 950-951
Nursing Process: Assessment NCLEX: Physiological Integrity

4. The nurse teaches a patient who is being stabilized on a therapeutic dose of warfarin (Coumadin) not to alter the normal dietary intake of green, leafy vegetables, dairy products, or meats, primarily because these foods
a. are a source of vitamin K and may alter the action of warfarin.
b. decrease the absorption of warfarin.
c. have a natural anticoagulant effect.
d. affect the activity of bowel bacteria responsible for vitamin K production.

A
Rationale: Because warfarin activity is affected by the level of vitamin K, the patient's intake of vitamin K-rich foods should be consistent. The absorption of warfarin is not affected by these foods. The foods do not have an anticoagulant effect or impact on the bowel bacteria activity.

Cognitive Level: Application Text Reference: p. 954
Nursing Process: Implementation NCLEX: Physiological Integrity

5. A 72-year-old patient with massive infection is 5 ft 2 in (155 cm) tall and weighs 92 pounds (42 kg). Laboratory results include hemoglobin 10.5 g/dl (105 g/L) and albumin 2.0 g/dl (20 g/L). Which additional information will be most useful when the nurse is determining the patient's nutritional status?
a. Blood pressure
b. Level of consciousness
c. Presence of edema
d. Food allergies

C
Rationale: Edema occurs when serum albumin levels and plasma oncotic pressure decrease, as occurs when a stressor such as infection is imposed on pre-existing poor nutritional status. The blood pressure and level of consciousness are not directly affected by protein-calorie malnutrition. Food allergies are not an indicator of nutritional status.

Cognitive Level: Application Text Reference: pp. 952, 956
Nursing Process: Assessment NCLEX: Physiological Integrity

6. When using a nutrition screening tool, the nurse can identify a patient at nutritional risk without further assessment when the patient has
a. pressure ulcers.
b. had a recent hip fracture.
c. been vomiting for 3 days.
d. had recent surgery.

A
Rationale: Malnutrition is a major risk factor for pressure ulcers; therefore, the presence of a pressure ulcer indicates that the patient is at nutritional risk. The other patient diagnoses are not independent risk factors for poor nutrition.

Cognitive Level: Comprehension Text Reference: p. 957
Nursing Process: Assessment NCLEX: Physiological Integrity

7. In evaluating a patient outcome of "chooses high-protein foods," the nurse knows the outcome has been met when for lunch the patient selects from the hospital menu
a. bacon and tomato sandwich, bean soup, and coffee with cream.
b. peanut butter and jelly sandwich, French fries, and whole milk.
c. barbequed chicken breast sandwich, fruit yogurt, and skim milk.
d. chicken noodle soup, grilled cheese sandwich, and apple juice.

C
Rationale: The poultry and dairy selected are all high in complete protein. Although the other responses have some high protein foods, they are not as high in protein.

Cognitive Level: Application Text Reference: p. 950
Nursing Process: Evaluation NCLEX: Physiological Integrity

8. A high-calorie, high-protein diet is provided for a patient with a fractured hip and severe protein-calorie depletion, but the patient eats only about 50% of each meal tray and then complains of feeling tired. The nurse will plan to
a. arrange for smaller portions to be served on patient trays.
b. serve multiple small feedings of high-calorie, high-protein foods.
c. give continuous tube feedings of liquid nutritional supplements.
d. administer intravenous feeding with parenteral nutrition solutions.

B
Rationale: Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients. Smaller serving sizes will not improve patient nutritional intake. Tube feedings or parenteral nutrition (PN) may be needed if the patient is unable to take in enough nutrients orally, but increasing the oral intake should be attempted first.

Cognitive Level: Application Text Reference: p. 958
Nursing Process: Planning NCLEX: Physiological Integrity

9. While caring for an older adult patient hospitalized with dehydration and moderate protein-calorie malnutrition (PCM), the nurse identifies a nursing diagnosis of risk for infection related to
a. decreased leukocyte activity and phagocytosis.
b. anemia of malnutrition.
c. muscle weakness and impaired coughing effort.
d. delayed wound healing.

A
Rationale: The patient's moderate PCM will decrease leukocyte activity and phagocytosis. A decrease in red blood cells (RBCs) does not increase risk for infection. Muscle wasting is a sign of more severe PCM. The patient does not have any open wounds.

Cognitive Level: Application Text Reference: p. 954
Nursing Process: Diagnosis NCLEX: Physiological Integrity

10. A 66-year-old patient recovering from surgery for cancer of the lung is thin and has an albumin level of 3.7 g/dl (37 g/L). The nurse will plan to teach the patient about
a. the need to increase protein intake during the patient's hospitalization period.
b. the requirement for high-protein and high-calorie foods for at least several weeks.
c. selecting foods that are high in protein but relatively low in calories.
d. picking protein-rich foods that are also low in calories derived from fat.

B
Rationale: After major surgery, the patient will require high-protein and high-caloric intake for several weeks to promote wound healing and decrease infection risk. Teaching the patient to increase protein during hospitalization will not meet the patient's needs during the entire time required for wound healing. The patient needs increases in both calories and protein. Fat is the best source of calories and should not be restricted when the goal is a high-calorie intake.

Cognitive Level: Application Text Reference: p. 958
Nursing Process: Planning NCLEX: Physiological Integrity

11. A patient with difficulty swallowing is started on continuous tube feedings of a full-strength commercial formula at 100 ml/hr. The patient has six diarrhea stools the first day. The action that is most appropriate for the nurse to take first is to
a. slow the tube feeding flow rate.
b. discontinue any water intake.
c. notify the health care provider about the need for a change in formula.
d. check residuals and hold feedings if any residual is found.

A
Rationale: Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water will dilute the feeding and improve absorption. Also, many supplemental feedings will cause dehydration unless water is administered in addition to the feeding. The nurse may notify the health care provider about the loose stools, but actions such as slowing the feeding will be initially used rather than changing the formula of the feeding. High residual volumes do not contribute to diarrhea.

Cognitive Level: Application Text Reference: pp. 963-964
Nursing Process: Implementation NCLEX: Physiological Integrity

12. A patient is receiving continuous tube feedings through a percutaneous endoscopic gastrostomy (PEG). To maintain safe and effective delivery of the tube feeding, the nurse should
a. flush the tube with 50 ml of water every 8 hours after checking for residual volume.
b. obtain a daily radiograph for verification of tube placement.
c. check tube placement and residual volume every 4-6 hours.
d. place the patient on the left side with the head of the bed elevated to 45 degrees.

C
Rationale: The tube placement and residual volume are assessed every 4 hours to ensure that the tube is correctly positioned and decrease the risk for aspiration. The amount of water needed depends on the type of formula being administered. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily radiographs are not needed. The patient should have the head elevated 30 to 45 degrees but does not need to be continuously on the left side.

Cognitive Level: Application Text Reference: p. 963
Nursing Process: Implementation NCLEX: Physiological Integrity

13. Parenteral nutrition (PN) containing amino acids and dextrose was ordered and hung 24 hours ago for a malnourished patient. The nurse observes that about 50 ml remaining in the PN container. Which action is appropriate at this time?
a. Infuse the remaining 50 ml and then hang a new container of PN.
b. Hang a new container of PN and change the IV tubing and filter.
c. Continue to use the same tubing and filter and hang a new container of PN.
d. Clarify with the health care provider if the new PN also requires a tubing and filter change.

C
Rationale: All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 ml will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.

Cognitive Level: Application Text Reference: p. 966
Nursing Process: Implementation NCLEX: Physiological Integrity

14. PN with a peripherally inserted central catheter (PICC) is initiated for a patient. After 6 hours of PN infusion, the nurse checks the patient's capillary blood glucose level and finds it to be 140 mg/dl (8.9 mmol/L). The most appropriate action by the nurse is to
a. notify the health care provider of the glucose level.
b. recheck the capillary blood glucose in 4 hours.
c. obtain a venous blood glucose specimen.
d. slow the infusion rate of the PN infusion.

B
Rationale: Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, the health care provider is not notified. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.

Cognitive Level: Application Text Reference: p. 967
Nursing Process: Implementation NCLEX: Physiological Integrity

15. A patient with protein-calorie malnutrition has undergone surgery and radiation therapy for a malignant tumor of the bowel. The health care provider orders PN for the patient. The nurse will evaluate that the PN is effective when the patient's
a. blood glucose is 110 mg/dl.
b. fluid intake and output are balanced.
c. surgical incision is healing normally.
d. serum albumin level is 3.7 mg/dl.

C
Rationale: Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored but do not indicate that the PN is effective. The albumin level is low normal but does not reflect adequate caloric intake, which is also important for the patient.

Cognitive Level: Application Text Reference: p. 954
Nursing Process: Evaluation NCLEX: Physiological Integrity

16. The hospital nurse educator is observing a new RN who is caring for a patient receiving PN through a single-lumen central line inserted in the right subclavian vein. Which action by the new RN indicates that the RN can safely care for the patient?
a. The new RN flushes the line after drawing a blood specimen.
b. The new RN reminds the patient to keep the right arm straight.
c. The new RN checks capillary blood glucose every 8 hours.
d. The new RN infuses the PN solution using an infusion pump.

D
Rationale: An infusion pump is used for PN administration. A single-lumen catheter should not be used to draw blood because of the risk for infection or clotting. There is no need to keep the arm straight when a central line is in place. The capillary blood glucose is checked every 4 to 6 hours.

Cognitive Level: Application Text Reference: p. 967
Nursing Process: Evaluation
NCLEX: Safe and Effective Care Environment

17. A 22-year-old patient is admitted to the hospital with anorexia nervosa. The patient is 5 ft 5 in (163 cm) tall and weighs 90 pounds (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. In planning care for the patient, the nurse places the highest priority on the nursing diagnosis of
a. ineffective health maintenance related to obsession with body image.
b. risk for decreased cardiac output related to electrolyte imbalance.
c. imbalanced nutrition: less than body requirements related to refusal to eat.
d. risk for activity intolerance related to anemia and weakness.

B
Rationale: The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are also appropriate for this patient but are not associated with risk for decreased cardiac output or death.

Cognitive Level: Application Text Reference: p. 969
Nursing Process: Planning NCLEX: Physiological Integrity

18. A patient with bulimia is admitted to the hospital with electrolyte disorders. Which patient behavior observed by the nurse is of most concern?
a. The patient only eats about 20% of breakfast.
b. The patient ambulates continuously in the hallway.
c. The patient goes into the bathroom after each meal.
d. The patient asks for laxatives to treat constipation.

C
Rationale: Self-induced vomiting after eating is a hallmark of bulimia and may lead to further electrolyte disturbances and associated problems such as cardiac dysrhythmias. The other behaviors are also characteristic of patients with bulimia but do not pose an immediate threat to the patient's physiologic status.

Cognitive Level: Application Text Reference: p. 968
Nursing Process: Assessment NCLEX: Physiological Integrity

19. All these nursing actions are included in the plan of care for a patient who is malnourished. Which action is appropriate for the nurse to delegate to a nursing assistant?
a. Offer the patient the ordered nutritional supplement between meals.
b. Assess the patient's strength while ambulating the patient in the room.
c. Monitor the patient for skin breakdown over the bony prominences.
d. Assist the patient to choose high-nutrition items from the menu.

A
Rationale: Feeding the patient and assisting with oral intake are included in nursing assistant education and scope of practice. Assessing the patient and assisting the patient in choosing high nutrition foods require LPN/LVN- or RN-level education and scope of practice.

Cognitive Level: Application Text Reference: pp. 955-959
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

20. A patient who has a wound infection after major surgery has only been taking in about 50% to 75% of the ordered meals and states, "Nothing on the menu really appeals to me." Which action by the nurse will be most effective in improving the patient's oral intake?
a. Order at least six small meals daily.
b. Have family members bring in favorite foods from home.
c. Teach the patient about high-calorie, high-protein foods.
d. Make a referral to the dietician.

B
Rationale: The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked foods might improve intake. The other interventions may also help improve the patient's intake, but the most effective action will be to offer the patient more appealing foods.

Cognitive Level: Application Text Reference: p. 958
Nursing Process: Implementation NCLEX: Physiological Integrity

21. When using a soft, silicone nasogastric tube for enteral feedings, the nurse will need to
a. flush the tubing after checking for residual volumes.
b. administer continuous feedings using an infusion pump.
c. replace the tube every 3 to 5 days to avoid mucosal damage.
d. avoid giving medications through the feeding tube.

A
Rationale: The soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume. Either intermittent or continuous feedings can be given. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes, but flushing after medication administration is important to avoid clogging.

Cognitive Level: Application Text Reference: p. 961
Nursing Process: Implementation NCLEX: Physiological Integrity

22. A patient who is receiving a continuous tube feeding through a small-bore silicone feeding tube has a computed tomography (CT) scan ordered and will have to be placed in a flat position for the scan. The nurse will plan to
a. ask the health care provider to reschedule the CT scan.
b. send the patient to CT scan with oral suction in case of aspiration.
c. shut the feeding off 30 to 60 minutes before the scan.
d. connect the feeding tube to continuous suction during the scan.

C
Rationale: The tube feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.

Cognitive Level: Application Text Reference: p. 963
Nursing Process: Planning NCLEX: Physiological Integrity

23. Which of these nursing actions included in the plan of care for a patient who is receiving intermittent tube feedings through a PEG tube may be delegated to an LPN/LVN?
a. Teaching the patient and family how to administer tube feedings
b. Assessing the patient's nutritional status at least weekly
c. Determining the need for the addition of water to the feedings
d. Providing skin care to the area around the tube site

D
Rationale: LPN/LVN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require RN-level education and scope of practice.

Cognitive Level: Application Text Reference: pp. 967-968
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

24. The nurse notes that the peripheral PN bag is almost empty and a new PN bag has not yet arrived from the pharmacy. Which action is appropriate?
a. Decreasing the rate of the current PN infusion to 10 ml/hr until the new bag arrives
b. Infusing 5% dextrose in water until the new PN bag is delivered from the pharmacy
c. Flushing the peripheral line with saline and wait until the new PN bag is available
d. Monitoring the patient's capillary blood glucose until a new PN bag is hung

B
Rationale: To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurse's scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose is appropriate but is not an adequate response because monitoring

Cognitive Level: Application Text Reference: p. 967
Nursing Process: Implementation NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. During a busy day, the nurse admits all of these patients to the medical-surgical unit. Which patients are most important to refer to the dietician for a complete nutritional assessment? (Select all that apply.)
a. A 24-year-old admitted with multiple leg fractures after an automobile accident
b. A 32-year-old admitted for eye surgery and has a history of diabetes
c. A 45-year-old admitted with chest pain and possible myocardial infarction (MI)
d. A 53-year-old who complains of intermittent nausea for the past 2 days
e. A 66-year-old who is admitted for débridement of an infected surgical wound

A, B, E
Rationale: Multiple fractures, diabetes, and poor wound healing are diagnoses that place the patient at nutritional risk. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.

Cognitive Level: Application Text Reference: p. 957
Nursing Process: Implementation NCLEX: Physiological Integrity

OTHER

1. While caring for a comatose patient who is receiving continuous tube feedings through a soft nasogastric tube, the nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take the following actions?
a. Obtain the patient's oxygen saturation.
b. Turn off the tube feeding.
c. Notify the patient's health care provider.
d. Check the tube feeding residual volume.

B, A, D, C
Rationale: The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume should be obtained because it provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained.

Cognitive Level: Application Text Reference: p. 963
Nursing Process: Implementation NCLEX: Physiological Integrity

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