Online Practice Test 50

Your Results for: "NCLEX® Review"

Print this page

Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 50 > NCLEX® Review Date/Time Submitted: August 2, 2012 at 2:19 AM (UTC/GMT)

Summary of Results 50% Correct of 10 Scored items: 5 Correct:  50% 5 Incorrect:  50% More information about scoring

1.		The nurse is to teach a client with Chronic Obstructed Pulmonary Disease safety precautions for using oxygen at home. The nurse knows that the client understands the safety principles discussed when he says the following: Your Answer: "Avoid materials that generate static electricity."
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: Oxygen is a highly combustible substance. When near a client using oxygen, smoke only outside or in a room provided for smoking, away from the client. Inappropriate substances for use are noted in answer 3. Fire extinguishers should be readily available, and there should be an individual/family member with knowledge of its use. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The nursing intervention that is appropriate for use with clients having an endotracheal tube is:  Your Answer: Frequently assessing nasal and oral mucosa for redness and irritation Correct Answer: Providing room air
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: Humidified air or oxygen should be given, because the endotracheal tube bypasses the upper airways, which normally moistens air. Notepads and picture boards help to give the client some control in communication with others. Frequent assessments of nasal and oral mucosa monitor for skin breakdown and infection. Placing the client in a side-lying position prevents aspiration of fluids, which can lead to infection. Nursing Process: Planning and Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Decide what is the best action for client and situation.
3.		Which is the appropriate method to use when a client is suffering respiratory difficulty and in need of suctioning? Your Answer: Portable or wall suction machine with tubing and collection receptacle
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: A dextrose-and-water solution is not used here. Controversy exists with using normal saline to assist in loosening secretions. The nasal cannula is not used in this technique. Goggles are worn for protection from any secretions splashed during the suctioning process. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
4.		Appropriate follow-up evaluation of a client after suctioning does not include which of the following assessments?  Your Answer: Only document findings abnormal in the client record; the doctor will see the results when rounds on the client are done.
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: All findings after suctioning clients are documented in the record. Abnormal findings are not only documented, but called to the physician's attention as well. All other actions are appropriate. Nursing Process: Assessment Client Need: Physiological Integrity Nursing Process: Analysis Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
5.		While suctioning a client in ICU, the nurse notices that the activity brings about deep breathing and coughing maneuvers by the client. This is considered a good action because:  Your Answer: Deep breathing oxygenates the lungs, and coughing loosens and moves secretions in the lungs.
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: The movement allows for expansion of the lungs, and the force and pressures exerted in coughing loosen the secretions. The other statements are not accurate. Nursing Process: Assessment Client Need: Physiological Integrity Nursing Process: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		An appropriate nursing responsibility in caring for clients with chest drainage systems would be: Your Answer: Monitoring the patency and integrity of the drainage system
		Objective: State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. Rationale: Actions taken directly from the text in book. No tube can drain effectively if it is clogged or damaged in any manner. The water seal level is marked for most effective level of use. Overfilling it adds no additional effectiveness. Clamps are readily available at the bedside for emergency purposes, such as dislodgement of the tube. Monitoring of client status after tube insertion includes all vital signs, and is set according to client need and hospital guidelines. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		Which client is most at risk for developing an upper respiratory infection? Your Answer: A 13-year-old with a broken leg Correct Answer: A 3-year-old in preschool
		Objective: Identify factors influencing respiratory function. Rationale: During infancy and childhood, upper respiratory infections are common due to changes in developing respiratory systems. Adolescents and young- and middle-adult individuals would suffer this problem only if their immune systems were compromised in any manner, or if they suffered from chronic illness. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		The nurse is providing wellness teaching to a group of seniors in the community. Which action is not appropriate to follow in promoting healthy breathing? Your Answer: (blank)
9.		Which clinical signs are indicative of hypoxia? (Select all that apply.) Your Answer: Flaring of nostrils Mouth breathing Cyanosis  Rapid pulse Substernal or intercostals retractions Correct Answers: Flaring of nostrils Cyanosis  Rapid pulse Substernal or intercostals retractions
		Objective: Describe nursing measures to promote respiratory function and oxygenation. Rationale: Signs of hypoxia include: rapid pulse, rapid, shallow respirations and dyspnea, increased restlessness and lightheadedness, flaring of the nares, substernal or intercostals retractions and cynaosis. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection. Objective: Describe nursing measures to promote respiratory function and oxygenation. Rationale: Signs of hypoxia include: rapid pulse, rapid, shallow respirations and dyspnea, increased restlessness and lightheadedness, flaring of the nares, substernal or intercostals retractions and cynaosis. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		_____________ or clapping is forceful striking of the skin with cupped hands to dislodge tenacious secretions.  Your Answer: Lifestyle Correct Answer: Time of day
		Objective: Identify and describe nursing measures to promote respiratory function and oxygenation. Rationale: Percussion is forceful striking with cupped hands and used to dislodge tenacious secretions. The nurse should cover the area with a towel or blanket, ask the client to breathe slowly, alternately flex and extend the wrists rapidly to slap the chest for 1 to 2 minutes. Nursing Process: Implementing Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge of pulmonary care.

Online Practice Test 49

Your Results for: "NCLEX® Review"

Print this page

Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 49 > NCLEX® Review Date/Time Submitted: August 2, 2012 at 1:40 AM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		The nurse is presenting information at the community health fair about normal defecation patterns across the lifespan. Which of the following factors would not be part of the discussion? Your Answer: Gender
		Objective: Understand the physiology of defecation. Rationale: There is no relationship noted between gender and defecation pattern. Diet, fluids, and medications all can affect amount, consistency, or pattern of defecation. Nursing Process: Implementation Client Need: Health Promotion and Maintenance and Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The elderly population is known to use laxatives with regularity. In advising an older adult practicing this habit, the nurse would identify all of the following except: (Select all that apply.)  Your Answer: Laxatives increase the absorption of certain vitamins. Correct Answers: Consistent use of laxatives inhibits natural defecation reflexes, and is thought to cause rather that cure constipation. Habitual use of laxatives eventually requires larger or stronger doses because the effect is progressively reduced. Laxatives may interfere with fluid and electrolyte balance.
		Objective: Identify measures that maintain normal fecal elimination patterns. Rationale: Laxatives decrease the absorption of vitamins. The remaining answer choices are true. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
3.		The nurse encounters a 75-year-old in the emergency department, with complaints of nausea, diarrhea, and anorexia. He has been evaluated, and it is determined that he can be treated at home. In discussing the guidelines of managing diarrhea, the nurse knows the client understands his care measures when he says:  Your Answer: "I will eat fried chicken for supper." Correct Answer: "I will increase foods with fiber, like oatmeal."
		Objective: Identify factors that influence fecal elimination and patterns of defecation. Rationale: Increasing roughage (fiber) in the diet helps to add bulk to the stool. Eight glasses of water remains the recommended fluid recommendation, although there is some disagreement. Beverages with caffeine, like tea, and fatty foods like fried chicken aggravate diarrhea. Nursing Process: Implementation Client Need: Physiologic Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and process of elimination.
4.		A client suffering with ulcerative colitis has discussed the need for a temporary colostomy to rest the colon and help the healing process. The colostomy will be located in the descending colon. The type of stool that the client can expect from this stoma is: Your Answer: Increasingly solid
		Objective: Describe essentials of fecal stoma care for clients with an ostomy. Rationale: Stool in the descending colon is often formed, and the tissue can be trained for periodic defecation. Liquid stool and malodorous stool that cannot be controlled is found within the ascending colon. Malodorous, mushy stool is noted in the transverse colon. Output is always expected at some point in time from ostomies as evidence of their functioning. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include: Your Answer: Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection
		Objective: Describe essentials of fecal stoma care for clients with an ostomy. Rationale: Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies avaliable for clients to help control odor that may be incurred because of the ostomy. Although a prescription for ostomy supplies is needed, you can order the supplies from any medical supplier. Dependent on the location and trainability of the ostomy, appliances are almost always worn throughout the day and when traveling. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Read question and prioritize nursing actions.
6.		At the local wellness fair, the nurse is asked to share information on having healthy bowel life. Included in this area is the topic of having a healthy defecation. The nurse should include which of the following information as appropriate action to follow? Your Answer: Establishing a regular exercise regimen
		Objective: Identify factors that influence fecal elimination and patterns of defecation. Rationale: Exercise helps to stimulate muscle functioning and metabolic activity, thus promoting healthy defecation. High-fiber foods are encouraged in the diet of this client. Do not avoid the urge to defecate, because this conditioned reflex tends to weaken or is ultimately lost. Six to eight glasses of water are recommended to maintain fluid balance in the body. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		An 80-year-old client is in the emergency department. The client complains of diarrhea and vomiting for the past two days. In assessing the client, it is noted that his skin is dry and can be tented, he has lost eight pounds, and is itchy. Which NANDA diagnosis would be most appropriate to use with this client in making his plan of care?  Your Answer: Risk for Deficient fluid volume related to prolonged diarrhea and vomiting
		Objective: Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. Rationale: This client is showing signs of dehydration. The first answer is the only appropriate answer. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
8.		When using a rectal tube in helping a client expel flatulence, the most appropriate intervention to be followed by the nurse is Your Answer: Encourage the client to assume various positions in bed once the tube is inserted.
		Objective: Identify measures that maintain normal fecal elimination patterns. Rationale: Varying the position from side-lying to sitting to supine helps the client to expel flatus. The side-lying position is recommended for use during insertion. Lubrication of the tube helps to ease the insertion process and prevent damage to the tissue. The tube should not be left in the client for more than 30 minutes, to avoid irritation to the rectal mucosa. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		A client has had a stroke, and can no longer move her bowels on her own accord. A bladder-training program is to be established for her. Before beginning this program, the client and her family members must understand what is involved with this care. Which of the following would be the most appropriate directions or information to share? Your Answer: Administer a cathartic suppository 30 minutes before the client's defection time to stimulate peristalsis
		Objective: Identify examples of nursing diagnoses, outcomes, and interventions for clients with elimination problems. Rationale: The best results can be obtained by inserting the suppository 30 minutes before the client's usual defecation time, or when the peristaltic action is greatest. The daily routine in bowel training is recommended to be 2-3 weeks. When the client experiences the urge to defecate, assist the client to the toilet/commode/bedpan to defecate. Fluid intake, increased fiber in the diet, intake of hot drinks, and increased exercise all influence one's ability to perform the action of defecation on a regular basis. Nursing Process: Analysis Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Read question and prioritize nursing actions.
10.		The nurse has completed the administration of a cleaning enema for a client being prepared for intestinal surgery. Complete documentation by the nurse of this event includes all but which of the following assessments? (Select all that apply.) Your Answer: Type of solution Length of time solution retained Amount of return Correct Answers: Type of solution Length of time solution retained Relief of flatus and abdominal distention
		Objective: Describe the purpose and action of commonly used enema solutions. Rationale: Document color, odor, amount and consistency of feces, and the condition of the perineal area. The remaining actions are also documented. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Read question and prioritize nursing actions. Objective: Describe the purpose and action of commonly used enema solutions. Rationale: Document color, odor, amount and consistency of feces, and the condition of the perineal area. The remaining actions are also documented. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Read question and prioritize nursing actions.

Online Practice Test 48

Your Results for: "NCLEX® Review"

Print this page

Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 48 > NCLEX® Review Date/Time Submitted: August 1, 2012 at 2:14 PM (UTC/GMT)

Summary of Results 60% Correct of 10 Scored items: 6 Correct:  60% 4 Incorrect:  40% More information about scoring

1.		A client comes to the primary care provider's office with the complaints of urinating all the time, pain on urination, small amounts of urine being passed when voiding, and a foul smell to the urine. A urine specimen has been sent for analysis. Based on the signs and symptoms expressed by the client, which of the following health problems would be anticipated? Your Answer: Urinary tract infection
		Objective: Identify common causes of selected urinary problems. Rationale: The noted signs and symptoms help to identify the problem of urinary tract infection. The signs and symptoms noted are not common with the other diseases listed. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		An appropriate health goal for clients with urinary elimination problems would include:  Your Answer: Preventing associated risks, such as infections and fluid and electrolyte imbalances.
		Objective: Develop nursing diagnoses, desired outcomes, and interventions related to urinary elimination. Rationale: Preventing associated risks related to urinary disease is the only appropriate goal noted. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		Which nursing assessment in the home care environment for clients with urinary elimination problems is inappropriate? Your Answer: No dietary restrictions needed
		Objective: Describe nursing assessment of urinary function including subjective and objective data. Rationale: Dietary guides related to fiber and fluid balance are given to clients with this problem. The remaining actions are noted in the assessment guide, and are appropriate measures to use with clients. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		The nurse is requested to perform teaching to a client in the Emergency Department related to the diagnosis of a urinary tract infection. An intervention to be followed by the client includes:  Your Answer: Voiding pattern in the course of the day has no significance with this problem. Correct Answer: Avoid tight-fitting pants or clothing
		Objective: Delineate ways to prevent urinary infection. Rationale: Tight-fitting clothing creates irritation to the urethra and prevents ventilation of the perineal area. It is recommended that eight glasses of water be drunk to flush out the urinary system. Avoid harsh soaps, bubble bath, powders, and sprays in the perineal area, because they can have an irritating effect on the urethra, encouraging inflammation and a bacterial infection. Practice frequent voiding (q 2-3 hours) to flush bacteria out other the urethra and prevent organisms from ascending into the bladder. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		Urinary incontinence is not a normal part of aging. An intervention used by nurses to assist clients to regain or maintain continence with individuals suffering from this problem would not include: Your Answer: Fluid restriction
		Objective: Develop nursing diagnoses, desired outcomes, and interventions related to urinary elimination. Rationale: Fluids would be encouraged, to allow the kidneys to be flushed and urine to be formed. Bladder training requires that the client postpone voiding, resist or inhinbit the sensation of urgency, and void according to a timetable, rather than according to an urge. Habit training is also referred to timed or scheduled voiding. There is no attempt to motivate the client to delay voiding if the urge occurs. Prompted voiding supplements habit training by encouraging the client to try to use the toilet and reminding the client when to void. Nursing Process: Implememtation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		Urinary catheterization is carried out for clients only when absolutely necessary. Which of the following candidates/situations would not warrant the need for this procedure? Your Answer: To collect a random urine specimen for evaluation
		. Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: Collection of a random urine specimen is not routinely obtained by use of the process of catheterization. The other candidates/situations are appropriate uses of this technique. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		The goal of nursing care of the client with an indwelling catheter and continuous drainage is largely directed at preventing infection of the urinary tract and encouraging urinary flow through the drainage system. Which of the following interventions encouraged by nurses working with these clients would not be appropriate in meeting this goal? Your Answer: Encouraging the client to eat foods that increase the acid in the urine Correct Answer: Changing indwelling catheters every 72 hours.
		Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: Retention catheters are removed after their purpose is achieved; routine changing of the catheter or drainage system is not recommended. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection. Eating foods that increase the acid in urine helps to reduce the risk of urinary tract infections and stone formation. Hygiene care related to catheters is set by hospital policy. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Which type of client would this type of procedure would benefit from this procedure?  Your Answer: A client with kidney stones Correct Answer: An abdominal trauma victim
		Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: The abdominal trauma victim is the only appropriate answer here. The remaining problems can be treated with less traumatic care measures. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		A practice guideline for nurses to use in preventing catheter-associated urinary infection includes which of the instructions listed below? Your Answer: Prevent contamination of the catheter with feces in the incontinent client.
		Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: Keeping the perineal area free of feces eliminates the possible spread of any bacteria that may colonize in the feces and travel up the catheter to the bladder. Sterile or aseptic technique is used when inserting Foley catheters into clients to prevent the spread of infection with the process. Catheter tubing should not be disconnected once put into use. Connections are usually taped to help secure their seal. Wearing gloves with this procedure is part of the practice of Universal Precautions utilized when health care workers come in contact with most tubes and body fluids. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		The nurse is counseling a young mother who complains of having stress incontinence continuing for three months after her pregnancy. It has been recommended that she practice pelvic muscle exercises to strengthen her bladder muscles. What action would the nurse recommend to this client in order to perform this activity correctly? Your Answer: Moving her bowels Correct Answer: Stopping urination midstream
		Objective: Develop nursing diagnoses, desired outcomes, and interventions related to urinary elimination Rationale: Stopping the flow of urination midstream focuses on the muscle used to control this activity. The remaining answers do not affect this muscle in the same manner. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection

Online Practice Test 47

Your Results for: "NCLEX® Review "

Print this page

Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 47 > NCLEX® Review Date/Time Submitted: August 1, 2012 at 1:57 AM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		While teaching a weight management class, the nurse explains the importance of fiber in the diet for health and weight management. When reviewing the content at the end of the class, the nurse is aware that there is a misunderstanding when a class member responds: Your Answer: "Fiber is a complex carbohydrate that takes a long time to digest, so a person will experience a decreased appetite."
		Objective: Identify essential nutrients and their dietary sources. Rationale: Fiber is a complex carbohydrate that cannot be digested, adds bulk, satisfies appetite, comes from plants, and aids digestion and waste elimination. Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The nurse reads a food label that indicates the following: Carbohydrates: 22 grams Fat: 7 grams Protein: 16 grams The nurse calculates the number of total calories to be:  Your Answer: 215 calories
		Objective: Identify essential nutrients and their dietary sources. Rationale: Calories are calculated from the amount of energy released from food metabolism. Carbohydrates and proteins release 4 calories/gram, and fat releases 9 calories/gram. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		When evaluating compliance with a health and weight loss plan, the nurse notes that which activity as most likely being responsible for a three-pound weight loss in the past month? Your Answer: Physical activity
		Objective: Discuss body weight and body mass standards. Rationale: Metabolism of food maintains and provides energy for the body. Exercise increases the metabolic rate and burns more calories. This causes weight loss. The other kinds of activity may cause some energy expenditure, but much less than the amount caused by physical activity. Nursing Process: Evaluation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		Which client assessed during screening for under- and over nourishment would be considered to be the healthiest? Your Answer: Male, 25 years old, 5 feet 6 inches, 160 pounds, BMI 25, Body fat 21% Correct Answer: Male, 25 years old, 5 feet 11 inches, 160 pounds, BMI 18, Body fat 17%
		Objective: Discuss body weight and body mass standards.  Rationale: Male, 25 years old, 5 feet 11 inches, 160 pounds, BMI 18, Body fat 17% is considered the healthiest based on the information given for BMI and body fat for the ages and heights listed. BMI of 25% or higher is considered overweight. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		The mother of a preschooler asks the nurse about snacks for her child. Which of the foods mentioned is not an age-appropriate snack? Your Answer: Yogurt Correct Answer: Fruit-flavored Popsicles
		Objective: Identify developmental nutritional considerations.  Rationale: Fruit-flavored Popsicles is not an age-appropriate snack. The preschooler should be eating more adult-like food. Their busy, active lifestyle leads to quick meals with a need for nutritious snacks. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		While performing a health assessment, a nurse notes risk factors for nutritional deficiencies. Which client is most likely to suffer a vitamin B deficiency? Your Answer: One who abuses alcohol
		Objective: Discuss essential components and purposes of nutritional screening and nutritional assessment. Rationale: Individuals with a sedentary lifestyle may have a tendency to eat fast foods that are high in salt and saturated fats. Vitamin B is found in low-fat meats. Someone who abuses alcohol is less likely to adhere to recommended nutritional guidelines. Pregnancy requires many additional nutrients. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection. Key words = "most likely"
7.		When eating properly, clients on vegetarian diets will eat a nutritionally complete diet. However, there is a risk of malnutrition of which nutrient?  Your Answer: Protein
		Objective: Discuss essential components and purposes of nutritional screening and nutritional assessment. Rationale: With vegetarian diets, there is a risk of not getting enough protein, since vegetarians don't eat meats that contain protein. Carotene and vitamin C are rich in vegetables. Vegetarians are at no greater risk of water deficiency than non-vegetarians. See Box 47-6, Combinations of Plant Proteins that Provide Complete Proteins. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		Which of the following menus is acceptable for a client on a soft diet? Your Answer: Sweet potatoes, shredded pork, and apple sauce
		Objective: Discuss nursing interventions to treat clients with nutritional problems. Rationale: Meat needs to be lean, tender, chopped, or shredded. Vegetables and fruits need to be cooked, creamed, mashed, and without membranes. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
9.		A client who has a feeding tube most likely has a nursing diagnosis of:  Your Answer: Impaired swallowing
		Objective: Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems.  Rationale: Impaired gas exchange is a possibility if a client is unable to swallow, and aspirates food or stomach contents. While possible, this is less likely than Impaired swallowing. A feeding tube will not help a client with constipation or delayed gastric emptying. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		Which client is most likely to receive total parenteral nutrition (TPN)? Your Answer: A client with severe malnutrition due to metastatic cancer who is in a hospice program Correct Answer: A client NPO following surgery for repair of gunshot wounds to the gastrointestinal system
		Objective: Plan, implement, and evaluate nursing care associated with nursing diagnoses related to nutritional problems. Rationale: TPN is used to achieve an anabolic state in clients unable to maintain a normal nitrogen balance. TPN is used for clients with serious illness unable to eat for more than five days. The client in Answer 1 is in the acute phase of an illness that is most likely self-limited. TPN is used for clients with metastatic cancer; however, the client in Answer 2 is facing the end of life and is less likely to be using this expensive medical treatment. Removal of a lung is serious surgery, but the client usually begins eating within five days after surgery. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.