nutrition practice Qs - Sheet1

Question 1

1. The nurse is caring for a patient with pneumonia, who has severe malnutrition. The patient’s condition places her at risk for which of the following life-threatening complications during hospitalization? (Select all that apply.)
2. Heart disease
3. Sepsis
4. Hemorrhage
5. Skin breakdown
6. Diarrhea

Answer 1

Answer: 2, 3, 4
Rationale: Severe malnutrition weakens the immune system, increasing the risk of sepsis. It also impairs clotting and healing processes, making hemorrhageand skin breakdown more likely.

Question 2

2. The nurse is preparing to perform a blood glucose monitoring test on a patient. Place the steps for performing the procedure in the correct sequence.
3. Press button on meter to confirm match codes.
4. Bringing meter to test strip, allow blood drop to wick onto test strip.
5. Instruct patient to perform hand hygiene with soap and water.
6. Clean patient finger with antiseptic swab.
7. Interpret results and document.
8. Check code on test strip vial.
9. Holding lancet to finger, press release button on machine.
10. Perform hand hygiene and put on clean gloves.

Answer 2

Answer: 3, 6, 1, 8, 4, 7, 2, 5
Rationale: This sequence ensures proper hygiene, accurate glucose testing, and safe practices.

Question 3

3. The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet. Suddenly the patient begins to choke. What is the priority nursing intervention?
4. Suction her mouth and throat.
5. Turn her on her side.
6. Put on oxygen at 2 L nasal cannula.
7. Stop feeding her.

Answer 3

Answer: 4
Rationale: The priority is to stop feeding to prevent further aspiration and assess the severity of the choking.

Question 4

4. The nurse is changing the PN tubing. What action should the nurse take to prevent an air embolus?
5. Have the patient turn on the left side and perform a Valsalva maneuver.
6. Have the patient cough vigorously when tubing is disconnected.
7. Have the patient take a deep breath and hold it.
8. Place patient in supine position with head of bed elevated 90 degrees.

Answer 4

Answer: 1
Rationale: The Valsalva maneuver increases thoracic pressure, reducing the risk of air embolism during tubing changes.

Question 5

5. A patient is receiving both PN and EN. When would the nurse collaborate with the health care provider and request a discontinuation of PN?
6. When 25% of the patient’s nutritional needs are met by the tube feedings
7. When bowel sounds return
8. When the central line has been in for 10 days
9. When 75% of the patient’s nutritional needs are met by the tube feedings

Answer 5

Answer: 4
Rationale: PN is discontinued when 75% of nutritional needs are met via EN to reduce the risk of complications associated with PN.

Question 6

6. A patient is receiving an enteral feeding at 65 mL/h. The GRV in 4 hours was 125 mL. What is the priority nursing intervention?
7. Assess bowel sounds.
8. Raise the head of the bed to at least 45 degrees.
9. Continue the feedings; this is normal gastric residual for this feeding.
10. Hold the feeding until you talk to the primary care provider.

Answer 6

Answer: 3
Rationale: A GRV of 125 mL is within normal limits for an hourly rate of 65 mL/h; therefore, feedings should continue.

Question 7

7. Which action can a nurse delegate to AP?
8. Performing glucose monitoring every 6 hours on a stable patient
9. Teaching the patient about the need for enteral feeding
10. Administering enteral feeding bolus after tube placement has been verified
11. Evaluating the patient’s tolerance of the enteral feeding

Answer 7

Answer: 1
Rationale: AP can perform routine tasks like glucose monitoring for a stable patient, as it does not require advanced knowledge or critical thinking.

Question 8

8. Which statement made by the parents of a 2-month-old infant requires further education by the nurse?
9. “I’ll continue to use formula for the baby until he is at least a year old.”
10. “I’ll make sure that I purchase iron-fortified formula.”
11. “I’ll start feeding the baby cereal at 4 months.”
12. “I’m going to alternate formula with whole milk, starting next month.”

Answer 8

Answer: 4
Rationale: Whole milk is not appropriate for infants under 12 months due to inadequate nutrients and potential for allergies. This statement requires correction.

Question 9

9. A nurse sees an AP perform the following interventions for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse?
10. Fastening tube to the gown with new tape
11. Placing patient supine while giving a bath
12. Monitoring the patient’s weight as ordered
13. Ambulating patient with enteral feedings still infusing

Answer 9

Answer: 2
Rationale: Placing a patient supine increases the risk of aspiration during continuous feedings. Immediate correction is necessary.

Question 10

10. A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.)
11. Change the dressing using sterile technique.
12. Change TPN containers every 48 hours.
13. Change the TPN tubing every 24 hours.
14. Monitor glucose levels to watch and assess for glucose intolerance.
15. Elevate head of the bed 45 degrees to prevent aspiration.

Answer 10

Answer: 1, 3
Rationale: Sterile technique for dressing changes and changing TPN tubing every 24 hours are critical to preventing central line-associated bloodstream infections (CLABSIs).