Ch. 36 Oral Nutrition

Question 1

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?

A. Give the client thin liquids.
B. Instruct the client to tuck their chin when swallowing.
C. Have the client use a straw.
D. Encourage the client to lie down and rest after meals

Answer 1

B. CORRECT: Tucking the chin when swallowing allows food to pass down the esophagus more easily.

Question 2

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 provides the body with the most energy?
A. Fat
B. Protein
C. Glycogen
D. Carbohydrates

Answer 2

D. CORRECT: 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 from depletion.

Question 3

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 client’s meal tray?

A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil soup

Answer 3

C. CORRECT: A low‑residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs (custard and yogurt) are appropriate for a low‑residue diet.

Question 4

A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client’s BMI indicates a healthy weight, underweight, overweight, or obese.

Answer 4

BMI = weight (kg) ÷ height (m2).
Step 1: Client’s weight (kg) and height (m) = 80 kg and 1.6 m
Step 2: 1.6 × 1.6 = 2.56 m2
Step 3: 80 ÷ 2.56 = 31.25
A BMI greater than 30 identifies obesity.

Question 5

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

Answer 5

A. CORRECT: Sensations of thirst diminish with age, leaving older adults more prone to dehydration.
B. CORRECT: These requirements do not change from middle adulthood to older adulthood. However, some older adults need additional vitamin and mineral supplements to treat or prevent specific deficiencies.
C. CORRECT: If older adults ingest insufficient calcium in the diet, they need supplements to help prevent bone demineralization (osteoporosis).

Question 6

A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A. Provide assistance with ambulation.
B. Monitor oxygen saturation.
C. Weigh the client weekly.
D. Obtain stool specimen for occult blood.
E. Schedule daily rest periods.

Answer 6

A. CORRECT: Assist the client when ambulating to prevent a fall because the client who has anemia can experience dizziness.
B. CORRECT: Monitor oxygen saturation when the client has anemia due to the decreased oxygen‑carrying capacity of the blood.
D. CORRECT: Obtain the client’s stool to test for occult blood, which can identify a possible cause of anemia caused from gastrointestinal bleeding.
E. CORRECT: Schedule the client to rest throughout the day because the client who has anemia can experience fatigue. Rest periods should be planned to conserve energy.

Question 7

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching?

A. Stools will be dark red.
B. Take with a glass of milk if gastrointestinal distress occurs.
C. Foods high in vitamin C will promote absorption.
D. Take for 14 days.

Answer 7

C. CORRECT: Vitamin C enhances the absorption of iron by the intestinal tract.

Question 8

A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A. “You will need a monthly injection of vitamin B12 for the rest of your life.”
B. “Using the nasal spray form of vitamin B12 on a daily basis can be an option.”
C. “An oral supplement of vitamin B12 taken on a daily basis can be an option.”
D. “You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet.”
E. “Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia.”

Answer 8

A. CORRECT: The client who had a gastrectomy will require monthly injections of vitamin B12 for the rest of their life due to lack of intrinsic factor being produced by the parietal cells of the stomach.
B. CORRECT: Cyanocobalamin nasal spray used daily is an option for a client who had a gastrectomy.

Question 9

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect?

A. Absent turgor
B. Spoon‑shaped nails
C. Shiny, hairless legs
D. Yellow mucous membranes

Answer 9

B. CORRECT: Deformities of the nails, such as being spoon‑shaped, are findings in a client who has anemia

Question 10

A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client?

A. The client needs an erythrocyte sedimentation rate (ESR ) test weekly.
B. The client should have their hemoglobin checked twice a week.
C. Oxygen saturation levels should be monitored.
D. Folic acid production will increase.

Answer 10

B. CORRECT: Include in the teaching that hemoglobin and hematocrit are monitored twice a week until the targeted levels are reached.

Question 11

A nurse is caring for a client following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure?

A. Client report of upper chest pain
B. Decreased urine output
C. Pallor
D. Temperature elevation

Answer 11

D. CORRECT: Fever is an indication of bowel perforation during a paracentesis

Question 12

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply.)

A. Obtain a capillary blood glucose four times daily.
B. Administer prescribed medications through a secondary port on the TPN IV tubing.
C. Monitor vital signs three times during the 12‑hr shift.
D. Change the TPN IV tubing every 24 hr.
E. Ensure a daily aPTT is obtained.

Answer 12

A. CORRECT: The client is at risk for hyperglycemia during the administration of TPN and can require supplemental insulin.
C. CORRECT: Vital signs are recommended every 4 to 8 hr to assess for fluid volume excess and infection.
D. CORRECT: It is recommended to change the IV tubing that is used to administer TPN every 24 hr.

Question 13

A nurse is providing care to a client who is 1 day postoperative following a paracentesis. The nurse observes clear, pale‑yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention?

A. Place a clean towel near the drainage site.
B. Apply a dry, sterile dressing.
C. Apply direct pressure to the site.
D. Place the client in a supine position

Answer 13

B. CORRECT: Application of a sterile dressing will contain the drainage and allow continuous assessment of color and quantity.

Question 14

A nurse is completing discharge teaching with a client who is 3 days postoperative following a transverse colostomy. Which of the following should the nurse include in the teaching?

A. Mucus will be present in stool for 5 to 7 days after surgery.
B. Expect 500 to 1,000 mL of semiliquid stool after 2 weeks.
C. Stoma should be moist and pink.
D. Change the ostomy bag when it is ¾ full

Answer 14

C. CORRECT: A pink, moist stoma is an expected finding for a colostomy.

Question 15

A nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hr ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take?
A. Remove the current bag and hang a new bag.
B. Infuse the remaining solution at the current rate and then hang a new bag.
C. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag.
D. Remove the current bag and hang a bag of lactated Ringer’s.

Answer 15

A. CORRECT: The current bag of TPN should not hang more than 24 hr due to the risk of infection

Question 16

A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient’s height is 5′6″ and his current weight is 325 lb. What would the nurse document as his BMI?

A) 50.5
B) 52.4
C) 54.5
D) 55.2

Answer 16

b. 52.4

Question 17

A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply.

A) Absence of nausea, vomiting
B) Weight gain
C) Bowel sounds within normal range
D) Large amount of gastric residue
E) Absence of diarrhea and constipation
F) Slight abdominal pain and distention

Answer 17

a, c, e. Criteria to consider when evaluating patient feeding tolerance include: absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits.

Question 18

A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process?

A) Stroke the underside of the patient’s chin to promote swallowing.
B) Serve meals in different places and at different times.
C) Offer a whole tray of various foods to choose from.
D) Avoid between-meal snacks to ensure hunger at mealtime.

Answer 18

a. To feed a patient with dementia, the nurse should stroke the underside of the patient’s 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 be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

Question 19

A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient?

A) Administering pain medication 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.

Answer 19

b. 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 telling the patient what he must eat is no guarantee that he will comply.

Question 20

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 and 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.

Answer 20

d. 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 consult for diet modification and food size and/or consistency.

Question 21

A nurse is evaluating patients to determine their need for parenteral nutrition (PN). 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

Answer 21

a, b, f.
Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract; and when oral intake has been or is expected to be inadequate over a 7- to 14-day period.

PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

Question 22

A nurse is feeding a patient who states that she is feeling 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 antiemetic 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 ice cream.

Answer 22

a. The first action of the nurse when a patient has 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.

Question 23

A 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

Answer 23

a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

Question 24

A nurse is caring for a newly placed gastrostomy tube of a postoperative 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 cleansing it.

Answer 24

a. 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. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.

Question 25

A nurse is assessing a patient who has been NPO (nothing by mouth) 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 patient’s abdomen is soft, nondistended, with bowel sounds.
D) The patient reports fullness and diarrhea after breakfast.

Answer 25

d. 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% to 75% of the food on the meal tray.

Question 26

A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric 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) Obtain an order for a radiographic examination of the tube.

Answer 26

d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement.

Question 27

Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18?

A) Risk for Imbalanced Nutrition: More Than Body Requirements
B) Imbalanced Nutrition: More Than Body Requirements
C) Readiness for Enhanced Nutrition
D) mbalanced Nutrition: Less Than Body Requirements

Answer 27

d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced.

Question 28

A nurse nutritionist is collecting assessment data for a patient who complains of “tiredness” and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm?

A) Malabsorption
B) Anemia
C) Protein depletion
D) Reduction in total muscle mass

Answer 28

b. Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased indicates anemia, if increased indicates dehydration. Serum albumin tests for malnutrition and malabsorption. Protein depletion and malnutrition are diagnosed with serum albumin, prealbumin, transferrin, and blood urea nitrogen tests. The creatinine test may indicate dehydration, reduction in total muscle mass, and severe malnutrition.

Question 29

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 nurse’s next action following this assessment?

A) Use warm water or air and gentle pressure to remove the clog.
B) Use a stylet to unclog the tubes.
C) Administer cola to remove the clog.
D) Replace the tube with a new one.

Answer 29

a. In order to remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.

Question 30

A nurse performs presurgical 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 a vegan
B) An older adult patient who takes daily nutritional drinks
C) A 43-year-old patient who takes ginkgo biloba and an aspirin daily
D) An infant who is breastfeeding

Answer 30

c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery.

Question 31

The nurse is helping a client who eats a normal diet of 2000 calories daily to read a nutritional label on a box of cereal. Which nutrient does the nurse identify as appropriate for this client?

A) sodium greater than 2400 mg
B) total fat greater than 65 g
C) saturated fat greater than 30 mg
D) cholesterol less than 300 mg

Answer 31

D) cholesterol less than 300 mg

Question 32

A woman consumes pasta, grains, and other carbohydrates for which purpose?

A) weight gain
B) energy
C) weight loss
D) source of fiber

Answer 32

B) energy

Question 33

A nurse is reviewing a client’s laboratory values. Which laboratory value would be indicative of a client’s level of malnutrition?

A) Creatinine
B) Hemoglobin
C) Serum albumin
D) Oxygen saturation

Answer 33

C) Serum albumin

Question 34

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?

A) Use a small syringe and insert 10 mL of air.
B) If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water.
C) Continue to instill air until fluid is aspirated.
D) Place the client in the Trendelenburg position to facilitate the fluid aspiration process.

Answer 34

B) If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water.

Question 35

A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?

A) To allow gas to accumulate and promote healing
B) To rest the gastrointestinal tract and promote healing
C) To increase mucus in the bowel that helps to promote healing
D) To prevent gas from forming in the bowel and interfere with healing

Answer 35

B) To rest the gastrointestinal tract and promote healing

Question 36

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?

A) new mother who is bottle-feeding an infant
B) older adult who lives with grown children
C) adolescent who is in the second trimester of pregnancy
D) middle-age male who works night shift

Answer 36

C) adolescent who is in the second trimester of pregnancy

Question 37

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

A) Allow the client privacy during mealtime.
B) Delegate feeding assistance to the unlicensed assistive personnel.
C) Assess when client generally eats meals.
D) Contact the healthcare provider to prescribe an appetite stimulant.

Answer 37

C) Assess when client generally eats meals.