Milestone Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity (Concepts for

Interprofessional Collaborative Care College Test Bank)

MULTIPLE CHOICE

1. A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six

months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best?

a. Ask the client if the weight loss was intentional.

b. Determine if there are food allergies or intolerances.

c. Perform a comprehensive nutritional assessment.

d. Perform a rapid bedside blood glucose test.

ANS: A

This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If

not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of

this assessment.

Depending on risk factors and other findings, a blood glucose test may be warranted.

DIF: Applying/Application REF: 1215

KEY: Nutrition| nutritional disorders| nutritional assessment| nursing assessment MSC: Integrated

Process: Nursing Process: Assessment

NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished

from marasmus with which finding?

a. Deficit of calories

b. Lack of all nutrients

c. Specific lack of protein

d. Unknown cause of malnutrition

ANS: C

Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition.

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DIF: Remembering/Knowledge REF: 1215

KEY: Nutritional disorders| nutritional assessment MSC: Integrated Process: Teaching/Learning

NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse is reviewing laboratory values for several clients. Which value causes the nurse to

conduct nutritional assessments as a priority?

a. Albumin: 3.5 g/dL

b. Cholesterol: 142 mg/dL

c. Hemoglobin: 9.8 mg/dL

d. Prealbumin: 28 mg/dL

ANS: B

A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at

highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low

hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

DIF: Remembering/Knowledge REF: 1218

KEY: Nutritional disorders| nutritional assessment| laboratory values MSC: Integrated Process: Nursing

Process: Assessment

NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

4. A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most

important?

a. Auscultate lung sounds after each feeding.

b. Check tube placement before each feeding.

c. Check tube placement every 8 hours.

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d. Weigh the client daily on the same scale.

ANS: B

For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding,

which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but

this will indicate a complication that has already occurred. Weighing the client is important to determine

if nutritional goals are being met.

DIF: Applying/Application REF: 1222

KEY: Nutritional disorders| tube feedings| equipment safety MSC: Integrated Process: Nursing Process:

Assessment

NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?

a. Administer an antiemetic.

b. Check the clients gastric residual.

c. Hold the feeding until the nausea subsides.

d. Reduce the rate of the tube feeding by half.

ANS: C

The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the

provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After

vomiting, a gastric residual will not be accurate. The nurse should not continue to feed the client while

he or she is vomiting.

DIF: Applying/Application REF: 1223 KEY: Nutritional disorders| tube feedings

MSC: Integrated Process: Nursing Process: Implementation

NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by

the nurse is best to prevent hyperosmolarity?

a. Administer free-water boluses.

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