Question: Which of the following is the primary purpose for asking a client to keep a 3- to 7-day food diary?
Answer Options: A. To allow the client to rely on health professionals to identify problem areas
B. To determine any changes in the client’s appetite
C. To evaluate any significant changes in body weight
D. To assess the pattern of intake and compare with daily reference intakes
Answer: D. To assess the pattern of intake and compare with daily reference intakes
Question: A nurse is planning to administer a dose of morphine sulfate IV for a client who is postoperative. Which of the following pain management protocols should the nurse use when caring for this client?
Answer Options: A. Withhold the medication for a respiratory rate of 14/min
B. Perform the IV injection over 1 min
C. Avoid administering opioid agonists on a fixed schedule
D. Have an opioid antagonist available during the administration
Answer: D. Have an opioid antagonist available during the administration
Question: Which of the following actions should a nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing?
Answer Options: A. Auscultate the client’s lungs
B. Place the tip of a tongue depressor on the client’s posterior tongue
C. Inspect the client’s uvula and soft palate with a penlight
D. Place fingers on the client’s throat at the level of the larynx and ask the client to swallow
Answer: A. Auscultate the client’s lungs
Question: A nurse is reviewing a client’s laboratory values. Which of the following information is correct regarding albumin levels and nutritional status?
Answer Options: A. Albumin level is a poor short-term indicator of protein status
B. Hydration status does not affect a client’s albumin level
C. An albumin level of 3.2 g/dL is within the expected reference range
D. Albumin level is calculated by keeping a 24-hr record of protein intake
Answer: A. Albumin level is a poor short-term indicator of protein status
Question: A charge nurse is reviewing anthropometric values with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
Answer Options: A. “Isolated measurements of height and weight are of greater significance than changes over time.”
B. “A weight increase of 4 pounds in a client who has renal failure indicates retention of 1,000 mL of fluid.”
C. “The client should be weighed on the same scale at the same time each day.”
D. “The ratio of height-to-wrist circumference is the most accurate way to identify obesity.”
Answer: C. “The client should be weighed on the same scale at the same time each day.”
Question: A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding?
Answer Options: A. A client who has a paralytic ileus
B. A client who has recently experienced facial trauma
C. A client who has dysphagia
D. A client who has a decreased appetite
Answer: C. A client who has dysphagia
Question: During a pain assessment, a nurse asks questions about the quality of an adult client’s pain. Which of the following statements by the client refers to pain quality?
Answer Options: A. “The pain in my abdomen began last night and has gotten worse.”
B. “My pain is at a 9 on a scale of 0 to 10.”
C. “My pain feels like I’m being stabbed by a knife.”
D. “The pain is worse when I bend over at my waist.”
Answer: C. “My pain feels like I’m being stabbed by a knife.”
Question: A nurse is caring for a client who was admitted to the emergency department for severe pain following a fall from a ladder. The client reports taking an opioid prescription for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question?
Answer Options: A. Morphine sulfate
B. Naloxone
C. Fentanyl
D. Hydromorphone
Answer: B. Naloxone
Question: A nurse is caring for a client who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the client with feeding?
Answer Options: A. Provide the client with a straw
B. Offer the client thin fluids
C. Elevate the head of the bed 45° to 90°
D. Place food in the weaker side of the mouth
Answer: C. Elevate the head of the bed 45° to 90°
Question: A nurse is caring for two clients who are 2 hr postoperative following the same procedure. Which of the following factors should the nurse expect to be similar for both clients?
Answer Options: A. Perception of the intensity of postoperative pain
B. Prescriptions containing guidelines for pain medication administration
C. Goal of pain management for each client
D. Level of pain indicated by each client on a numeric pain scale
Answer: B. Prescriptions containing guidelines for pain medication administration
Question: A nurse is caring for a client prescribed IV morphine via PCA with a demand of 1 mg every 15 min and a 4 mg/hr lockout. The client reports unbearable pain after attempting six demand doses within the last hour. After assessing the client’s pain, which of the following actions should the nurse take?
Answer Options: A. Check the IV site and PCA pump for proper functioning
B. Teach the client proper use of the PCA system
C. Ask the provider to increase the morphine dose and shorten the interval between doses
D. Encourage family members to administer a dose of morphine via PCA when the client is in too much pain to do it themselves
Answer: A. Check the IV site and PCA pump for proper functioning
Question: A nurse is caring for a client who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this client undergo which of the following?
Answer Options: A. Chest x-ray
B. Swallowing examination
C. Nasogastric tube insertion
D. Olfactory nerve evaluation
Answer: B. Swallowing examination
Question: When teaching the guardian of a toddler about feeding and eating, the nurse should include which of the following safety measures?
Answer Options: A. Do not give the child peanut butter
B. Have the child drink 28 to 32 oz of milk daily
C. Give the child 8 to 12 oz of fruit juice daily
D. Do not offer the child raw vegetables
Answer: D. Do not offer the child raw vegetables
Question: Which of the following food choices are appropriate for a client who is prescribed a full liquid diet? (Select all that apply.)
Answer Options: Plain yogurt
Custard
Ice cream
Mashed potatoes
Pureed meat
Gelatin
Answer: Plain yogurt; Custard; Ice cream; Gelatin
Question: A client has finished a 16-oz container of orange juice. The intake and output sheet documents fluid in milliliters. What amount should the nurse document as the client’s intake?
Answer Options: (fill-in)
Answer: 480 mL
Question: Which of the following dietary modifications should an adolescent who participates in sports implement?
Answer Options: A. Increase fats to 30% to 40% of daily kilocalories
B. Drink water before and after sports activities
C. Keep protein intake at the same level
D. Decrease carbohydrates to 30% to 40% of daily kilocalories
Answer: B. Drink water before and after sports activities
Question: Which of the following interventions should a nurse use at mealtimes for a client who has visual impairment?
Answer Options: A. Identify the food location as though the plate were a clock
B. Direct the order in which food items are consumed
C. Have the client tilt their head forward while eating
D. Avoid talking to the client during mealtime
Answer: A. Identify the food location as though the plate were a clock
Question: A nurse is speaking with a client who reports experiencing frequent, severe migraines and asks, “Can you tell me about biofeedback?” Which of the following responses should the nurse make?
Answer Options: A. “Biofeedback measures skin tension and uses learned techniques to relieve pain.”
B. “Biofeedback provides soothing visual images identified by the client to promote relaxation.”
C. “Biofeedback includes listening to an increasing volume of music until the pain subsides.”
D. “Biofeedback stimulates the skin with a mild electric current when pain occurs.”
Answer: A. “Biofeedback measures skin tension and uses learned techniques to relieve pain.”
Question: A nurse is preparing to assess the pain level of a 4-year-old child. Which of the following pain assessment tools should the nurse use?
Answer Options: A. CRIES instrument
B. COMFORT Behavior scale
C. FACES
D. PAINAD scale
Answer: C. FACES
Question: Which of the following strategies for enhancing the intake of healthy foods is appropriate for an adolescent?
Answer Options: A. Encouraging the adolescent to consume snack foods from the grains food group
B. Permitting the adolescent to skip breakfast to enhance appetite at later meals
C. Making healthful food choices more convenient and available for the adolescent
D. Allowing the adolescent complete autonomy in making food choices
Answer: C. Making healthful food choices more convenient and available for the adolescent