Ch 19

Question 1

The nurse is assessing a client’s intake of micronutrients. The nurse would consider the intake of which of the following?

1. Carbohydrates, proteins, and fats
2. Fat-soluble vitamins and protein
3. Vitamins and minerals
4. Minerals and carbohydrates

Answer 1

3

Question 2

While caring for a client with a medical diagnosis of anorexia and malnutrition, the nurse needs to assess for which of the following? Select all that apply

1. Reduced cardiac output
2. Impaired pulmonary function
3. An incompetent immune response
4. Altered functional abilities
5. Dysphagia

Answer 2

2, 3, and 4

Question 3

The nurse is preparing to assess the nutritional status of an older adult client in a long-term care facility. What screening tool would best suit this purpose?

1. A comprehensive nutritional assessment
2. The Nutrition Screening Initiative
3. The Patient-Generated Subjective Global Assessment
4. A daily nutrition intake log

Answer 3

2

Question 4

The nurse is caring for a client who is 48 hours post bowel resection with creation of a colostomy. This morning the nurse assessed the return of bowel sounds. In what order would this client’s diet progress?

1. Full liquid diet
2. Regular diet
3. Clear liquid diet
4. NPO
5. Soft diet

Answer 4

4, 3, 1, 5, and 2

Question 5

The nurse would anticipate the need for an enteral access device in which client?

1. A client who has severe acute dysphagia
2. A client whose bowel sounds have not yet returned after abdominal surgery
3. A client who dislikes the taste of facility meals
4. A client who recently had a cerebrovascular accident

Answer 5

1

Question 6

The nurse is caring for a client in a chronic vegetative state with inadequate gastric emptying. What type of enteral access device would the nurse anticipate finding in this client?

1. Nasogastric tube
2. Nasoenteric tube
3. Gastrostomy tube
4. Jejunostomy tube

Answer 6

4

Question 7

If the nurse is administering bolus intermittent feedings, the enteral access device must be what type?

1. Nasojejunal
2. Percutaneous jejunostomy
3. Gastrostomy
4. Nasointestinal

Answer 7

3

Question 8

The nurse is caring for a client with a nasogastric feeding tube in place. What interventions would the nurse perform to reduce the risk of clogging the tube when administering feedings or medications? Select all that apply

1. Administer the feeding and medication as fast as possible so they cannot solidify in the tube
2. Mix medication with feeding to dilute the medication thoroughly
3. Flush the tube liberally with water before, between, and after each medication instillation
4. Use the largest barrel syringe possible to reduce the pressure in the tube
5. Crush solid medications thoroughly and mix in water before instillation

Answer 8

3, 4, and 5

Question 9

The nurse has just inserted a nasogastric tube. All of the following methods are acceptable means of assessing placement except:

1. Aspirate the tube to determine if gastric contents are obtained
2. Test contents aspirated from the tube for pH
3. Perform a radiologic examination
4. Auscultate the epigastrium while instilling 60mL of air

Answer 9

4

Question 10

The nurse is caring for a client who requires assistance with eating. The client repeatedly apologizes to the nurse, saying “I’m such a burden. I can’t even feed myself. I’m like a little baby. I’m so sorry.” What strategy is the most appropriate for the nurse to use?

1. Feed the client quickly so as not to make the client feel like it is taking a great deal of time out of the nurse’s day
2. Appear unhurried, sit at the bedside, and encourage the client to feed themselves as much as possible
3. Feed all of the solid foods first then offer liquids
4. Minimize conversation so that the client can eat faster

Answer 10

2