1. The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best?

a.            “Yes. Your body mass index suggests you are slightly overweight.”

b.            “Maybe. Let’s look at your risks for cardiovascular disease.”

c.             “Your weight is just fine. Don’t worry about it.”

d.            “No. In fact, your body mass index suggests that you are already underweight.”

ANS: D

The client’s body mass index (BMI) is 18.0, so she is already underweight. It is inaccurate to tell the client she is overweight, and it is unnecessary to consider her weight in light of any cardiovascular risk factors. The nurse should not reassure the client that her weight is just fine because she is underweight.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is caring for a male client who is 6 feet, 1 inch tall and weighs 215 pounds. The client asks the nurse if his weight is appropriate for his height. Which is the nurse’s best response?

a.            “Your weight is just about right for someone your height.”

b.            “Your weight is a few pounds under the ideal for your height.”

c.             “Your weight is a few pounds over the ideal for your height.”

d.            “Your weight is quite a few pounds over the ideal for your height.”

ANS: C

The client’s BMI is 28.4, indicating that the client is overweight. However, he is not obese. The nurse should not state that the client’s weight is just about right, a few pounds under, or quite a bit over the ideal weight for his height.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Therapeutic Communications)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is caring for a client who is a vegan and has developed B12 deficiency. Which foods does the nurse encourage the client to include in the diet?

a.            Fortified cereals and tofu

b.            Pumpkin seeds and blackstrap molasses

c.             Kale, spinach, and whole grain bread

d.            Strawberries and sweet red peppers

ANS: A

Megaloblastic anemia is caused by lack of folic acid and vitamin B12 in the diet. Vegans are susceptible to this and need to include fortified cereals, soy beverages, or meat substitutes in their diets. The other foods listed are not good sources of folic acid and vitamin B12.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning

4. The nurse is caring for a client who has a new small-bore nasoduodenal tube for feedings. Which intervention most effectively prevents clogging of the tube?

a.            Administering medications that have been thoroughly crushed and dissolved in cold water

b.            Flushing the feeding tube with 60 mL of cranberry juice or carbonated beverage four times daily

c.             Irrigating the tube with water before and after administration of medications using 20 to 30 mL

d.            Diluting the tube feeding to half-strength with cold water before infusion into the feeding tube

ANS: C

Irrigating the feeding tube with 20 to 30 mL of warm water before and after medication administration will help maintain patency of the tube. Irrigation with cranberry juice or carbonated beverages is not recommended. Administration of only liquid medications (not crushed and dissolved in liquid) through the tube will help prevent clogging. Dilution of tube feeding should not be done without an order from the provider.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 63-5, p. 1346

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures) MSC: Integrated Process: Nursing Process (Implementation)

5. The nurse is reviewing recent laboratory values for a client who is being treated for malnutrition. Which laboratory finding indicates that the client is not receiving adequate iron supplementation?

a.            Hematocrit, 31%

b.            Serum albumin, 3.5 g/dL

c.             Creatine phosphokinase (CPK), 55 U/mL

d.            Erythrocyte sedimentation rate (ESR), 15.8 mm/hr

ANS: A

Hematocrit is an indicator of iron status. Low hematocrit may indicate that the client has not received enough iron supplementation and remains anemic. Serum albumin indicates protein intake and CPK is a measure of muscle injury. An elevated ESR indicates inflammation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is caring for a client on a limited income who has been diagnosed with kwashiorkor. Which foods does the nurse suggest to improve the client’s nutritional status with minimal increase in food costs?

a.            Oatmeal and bananas

b.            Tomato soup with oyster crackers

c.             Omelet made with cheddar cheese

d.            Whole wheat pasta with tomato sauce

ANS: C

Kwashiorkor develops as a result of lack of protein intake despite adequate calories. The client needs to increase protein-containing foods. Eggs and cheese are high-protein foods that are less expensive than meats. Pasta, vegetables, fruit, and oatmeal have less protein than eggs and cheese.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning

7. The nurse is preparing to administer tube feedings through a client’s new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse?

a.            Start the tube feeding as ordered and check the residual in 30 minutes.

b.            Inject air into the nasogastric tube while auscultating the client’s epigastric area.

c.             Lower the head of the client’s bed and attempt to aspirate fluid again.

d.            Obtain orders for a chest x-ray to confirm placement before starting the feeding.

ANS: D

The nurse must verify tube placement before beginning any tube feeding or administering any medications through a tube. The most accurate way to determine placement is via chest x-ray. The nurse could cause the client to aspirate if she or he started the feeding then checked later for placement. Insufflation does not provide accurate results and should not be used to verify tube placement. The nurse must keep the client’s head elevated at least 30 degrees.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation