Fundamentals Exam 3 NCLEX Test Questions & Answers (Explained)-A nurse is caring for a client who is at high risk for aspiration. Which of the following
... [Show More] actions should the nurse take?
A. Give the client thin liquids
B. Instruct the client to tuck her chin while swallowing
C. Have the client use a straw.
D. Encourage the client to lie down and rest after meals - B
exp.) tucking the chin when swallowing allows food to pass down the esophagus more easily
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provide the most energy?
A. Fat
B. Protein
C. Glycogen
D. Carbohydrates - D
exp.) carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins for depletion.
A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the clients meal tray?
A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil soup - C
exp.) A low residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs such as custard and yogurt, are appropriate.
A nurse is caring for a client who weighs 80 kg (176 lbs) and 1.6 m (5 ft, 3 in tall) Calculate her body mass index (BMI) and determine whether this clients BMI indicates she is of a healthy weight, overweight, or obese. - BMI = weight (kg) / height (m2)
Step 1: Clients weight (kg) and height (m) = 80 kg and 1.6 m
Step 2: 1.6 X 1.6 = 2.56 m2
Step 3: 80/2.56 = 31.25
So this client is considered obese (BMI over 30 indicates obesity)
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply).
A. Older adults are more prone to dehydration than younger adults are
B. Older adults need the same amount of most vitamins and minerals as younger adults do
C. Many older men and women need calcium supplementation
D. Older adults need more calories than they did when they were younger
E. Older adults should consume a diet low in carbohydrates. - A
exp.) sensations of thirst diminish with age, leaving older adults more prone to dehydration
B
exp.) requirements for vitamins and minerals do not change from middle to older adulthood
C
exp.) if older adults ingest insufficient calcium in the diet, the need supplements to help prevent bone demineralization (osteoporosis)
A nurse is calculating the body mass index of a 35 year old male patient who is extremely obese. The patients height is 5'6 and his current weight is 325 lbs. What would the nurse document as his BMI?
A. 50.5
B. 52.4
C. 54.5
D. 55.2` - BMI = weight in pounds (325) / height in inches (66) X height in inches (66) X 703
BMI = 52.4
A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to deplete per day in order to accomplish this goal?
A. 250 calories
B. 500 calories
C. 750 calories
D. 1000 calories - D
exp.) 1 lb (0.45 kg) of body fat equals about 3.500 calories. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increase or decreased by 500 cals a day so to lose or gain 2 lbs per week, the calorie intake should increase or decrease by 1000 cals a day
A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process?
A. Stroke the underside of the patients chin to promote swallowing
B. Serve meals in different places at different times
C. Offer a whole tray of various foods to choose from
D. Avoid between-meal snacks to ensure hunger at mealtime - A
exp.) to feed a patient with dementia, the nurse should stroke the underside of the patients chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may overwhelming and provide between-meal snacks that are easy to consume using the hands
A 56 year old male patient who has COPD is refusing to eat. Which intervention would be most helpful in simulating his appetite?
A. Administering pain meds after meals
B. Encouraging food from home when possible
C. Scheduling his respiratory therapy before each meal
D. Reinforcing the importance of his eating exactly what is delivered to him - B.
exp.) Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and tells the patient what he must eat is no guarantee that he will comply
A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient?
A. Feed the patient solids first then liquids last
B. Place the head of the bed at a 30 degree angle during feeding
C. Puree all foods to a liquid consistency
D. Provide a 30 minute rest period prior to mealtime - D.
exp.) when feeding a patient who has dysphagia, the nurse should provide a 30 minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90 degree angle; and initiate a nutrition consultant for diet modification and food size and/or consistency
A nurse is evaluating patients to determine their need for total parenteral nutrition. (TPN) Which patients would be the best candidates for this type of nutritional support? Select all that apply
A. A patient with irritable bowel syndrome who has intractable diarrhea.
B. A patient with celiac disease not absorbing nutrients from the GI tract.
C. A patient who is underweight and needs short term nutritional support
D. A patient who is comatose and needs long term nutritional support
E. A patient who has anorexia and refuses to take foods via the oral route
F. A patient with burns who has not been able to eat adequately for 5 days - A, B, F
A nurse is feeding a patient who states that she is feeling is nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?
A. Remove the tray from the room
B. Administer an antiemtetic and encourage the patient to take small amounts
C. Explore with the patient why she does not want to eat her food
D. Offer high-calorie snacks such as pudding and icecream - A
exp.) the first action of the nurse when a patient ha nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect
A 62 year old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition?
A. Vitamin B malnutrition
B. Obesity
C. Dehydration
D. Vitamin C deficiency - A
exp.) the need for vitamin B is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply.
A nurse is caring for a newly placed gastrostomy tube of a post op patient. Which nursing action is performed correctly?
A. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site
B. The nurse wets a washcloth and washes the area around the tube with soap and water
C. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube
D. The nurse tapes a gauze dressing over the site after cleaning it - A
exp.) when caring for a new gastrostomy tube, the nurse would use a cotton tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage.
A nurse is assessing a patient who has been NPO prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced?
A. The patient consumed 75% of the liquids on her breakfast tray
B. The patient tells you she is hungry
C. The patients abdomen is soft, nondistended, with bowel sounds
D. The patient reports fullness and diarrhea after breakfast. - D
exp.) tolerance of diet can be assessed by the following: absence of nausea, vomiting and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50-75% of the food on the meal tray
A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastic tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube?
A. Auscultate the bowel sounds
B. Measure the gastric aspirate ph
C. Measure the amount of residual in the tube
D. order radiographic examination of the tube - D
Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index of 18?
A. Risk for Imbalanced Nutrition: More Than Body Requirements
B. Imbalanced Nutrition: More than Body Requirements
C. Readiness for Enhanced Nutrition
D. Imbalanced Nutrition: Less than Body Requirements - D
exp.) BMI of 18 is considered underweight
A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and shows signs of respiratory distress. What would be the priority action of the nurse upon this assessment?
A. Keep the tube in place and notify the primary HCP immediately
B. Stop advancing the tube and pull it back into the nasal area
C. Ask the patient if he wants the nurse to stop the procedure
D. Call for help for perform CPR - B
A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurses next action following this assessment?
A. Use warm water and gentle pressure to remove the clog
B. Use a stylet to unclog the tube
C. Administer cola to unclog the tube
D. Replace the tube with a new one - A
A nurse performs surgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed?
A. A 19 year old patient who is vegan
B. An elderly patient who takes daily nutritional drinks
C. A 43 year old patient who takes gingko bilboa and an aspirin daily
D. An infant who is breast feeding - C
exp.) A patient taking gingko biloba (an herbal) aspirin and vitamin E may have to have surgery postponed due to an increase risk for excessive bleeding, because each of those substances have anticoagulant properties.
A nurse is a providers office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (Select all that apply).
A. Limit total daily fluid intake
B. Decrease or avoid caffeine
C. Take calcium supplements
D. Avoid drinking alcohol
E. Use the crede maneuver - B, D
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?
A. Check to see whether the catheter is patent
B. Reassure the client that it is not possible for her to urinate
C. Recatheterize the bladder with a larger-gauge catheter
D. Collect a urine specimen for analysis - A
exp.) a clogging or kinked catheter causes the bladder to fill and stimulates the need to urinate
A nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take?
A. Discard the first voiding
B. Keep the urine in a single container at room temperature
C. Ask the client to urinate and pour the urine into a specimen container
D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container - A
exp.) the nurse should discard the first voiding of the 24 hr urine specimen and note the time
A nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTI's. Which of the following factors should the nurse include? (Select all that apply)
A. Frequent sexual intercourse
B. Lowering of testosterone levels
C. Wiping from front to back
D. Location of the urethra in relation to the anus
E. Frequent catheterization - A, D, E
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply)
A. Establish a schedule of urinating prior to meal times
B. Have the client record urination times
C. Gradually increase urination intervals
D. Remind the client to hold urine until the next scheduled urination time
E. Provide a sterile container for urine - B, C, D
A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for lab testing. Which techniques for urine collection are performed correctly? (Select all that apply)
A. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis.
B. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick up.
C. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter.
D. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture
E. The nurse collects a urine specimen from a patient with urinary diversion by catheterizing the stoma.
F. The nurse discards the first urine of the day when performing a 24 hr urine specimen collection on a patient. - D, E, F [Show Less]