Question 1

The nurse is planning to administer an intermittent enteral feeding through an NG tube. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Aspiration prevention is the priority during gastric enteral feedings, and upright positioning reduces gastroesophageal reflux and the risk of formula entering the airway. Keeping the head of bed at 30–45° during the infusion is a standard safety intervention for intermittent NG feedings. Infusing rapidly increases intolerance (nausea, cramping) and aspiration risk rather than improving nutrition delivery. Tube placement should be verified before administering the feeding, and supine positioning after feeding would increase aspiration risk.

Question 2

The client with a BMI of 30 is attending a health promotion program at a clinic. Which outcome is best for the nurse to document in the client’s plan of care?

Accepted Answer

Answer reason: Outcomes in a plan of care should be patient-centered, specific, measurable, and time-limited. With a BMI of 30 (obesity), a short-term weight-loss goal with a defined rate and timeframe provides an objective metric to evaluate progress in a health promotion program. A steady weekly loss aligns with commonly taught safe, sustainable weight-reduction targets and supports ongoing reassessment of diet/activity adherence. In contrast, the teaching and calling statements describe nursing interventions rather than measurable client outcomes, and weight gain would be inconsistent with the health promotion goal for obesity.

Question 3

A client must choose a meal that follows his diet orders of a high-calorie, high-protein, low-sodium, and low-potassium diet. Which choice indicates to the nurse that the client understands the dietary guidelines?

Accepted Answer

Answer reason: Fish provides high-quality protein, and adding ice cream increases calorie density without adding a major potassium load compared with common high-potassium choices. Rice and green beans are generally lower in potassium than baked potatoes or spinach, making them better starch/vegetable selections for potassium restriction. Options containing baked potato and spinach are classic high-potassium items, and items like crab can be higher in sodium depending on preparation, making those choices less consistent with the ordered diet.

Question 4

The nurse is assisting the client diagnosed with cardiac valve disease to choose a menu for the next day. Which menu is most appropriate for this client?

Accepted Answer

Answer reason: Clients with valvular heart disease are commonly taught to follow a heart-healthy diet that limits saturated fat and especially sodium to reduce fluid retention and cardiac workload. This option is the lowest in obvious high-sodium, highly processed foods and avoids fried items, chips, and cured meats that are typically very salty. Choosing water over sweetened beverages supports avoiding excess calories and helps with overall cardiovascular risk reduction. By contrast, menus featuring ham, cheese, chips, bacon, or gravy are classic higher-sodium choices that can worsen volume status and symptoms such as edema or dyspnea.

Question 5

The nurse is providing diabetic education to a group of clients with previously diagnosed diabetes. One of the clients asks what the advantage is in using a continuous subcutaneous pump. What is the best response by the nurse?

Accepted Answer

Answer reason: Continuous subcutaneous insulin infusion provides a programmable basal rate with on-demand bolus dosing, which supports varying meal schedules and carbohydrate intake. This improves lifestyle flexibility compared with fixed regimens that require strict meal timing to match insulin peaks. It is not “easy” and typically requires substantial education on pump operation, site care, troubleshooting, and glucose monitoring. It also does not eliminate diabetic ketoacidosis risk; in fact, interruption of rapid-acting insulin delivery can precipitate it, and pumps are generally not cheaper than injections due to device and supply costs.

Question 6

The nurse is planning to address diabetic meal planning with the client recently diagnosed with type 1 DM. Which action should the nurse take first?

Accepted Answer

Answer reason: Effective nutrition teaching starts with assessing the client’s current patterns, preferences, and routines so education can be individualized and realistic. Identifying usual meal timing and preferred foods allows the nurse to align insulin action with carbohydrate intake and to anticipate barriers to adherence. Once baseline habits are known, the nurse can then teach carbohydrate counting and strategies for consistent intake to reduce hypo/hyperglycemia risk. Focusing first on specific substitutions (e.g., sweeteners) is narrower and may miss the larger pattern issues that drive glycemic control.

Question 7

The nurse is discharging the client after Billroth H surgery (gastrojejunostomy). To assist the client to control dumping syndrome, which information should the nurse include in the client's discharge instructions?

Accepted Answer

Answer reason: Dumping syndrome occurs when rapid gastric emptying pulls fluid into the small intestine and triggers vasomotor symptoms after meals. Postprandial recumbency helps slow gastric emptying and reduces the sudden intestinal fluid shift, improving symptoms such as cramping, diarrhea, and dizziness. In contrast, drinking fluids with meals can worsen dumping by increasing intestinal volume and speeding transit; fluids are typically separated from meals. Dietary teaching also emphasizes small frequent meals with higher protein/fat and lower simple carbohydrates, which aligns with slowing absorption rather than accelerating it.

Question 8

The nurse assesses that the client who is receiving radiation for cervical cancer continues to have diarrhea. Which nursing advice is most appropriate for this client?

Accepted Answer

Answer reason: Radiation to the pelvis can inflame the intestinal mucosa, leading to diarrhea and increased risk of perianal skin breakdown. A low-residue diet reduces stool volume and frequency, helping decrease GI irritation while symptoms persist. Sitz baths provide gentle cleansing and soothing comfort for irritated perineal/rectal tissues without excessive friction. Other choices add unnecessary electrolyte manipulation (e.g., low potassium, high sodium) or increase lactose intake, which can worsen diarrhea, and do not prioritize evidence-based skin comfort measures for radiation-associated diarrhea.

Question 9

A client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which dietary modification is appropriate for this client?

Accepted Answer

Answer reason: Restricting saturated fat to under 7% of total calories is a standard therapeutic target for dyslipidemia and coronary risk reduction and most directly addresses elevated LDL. A general cap like “less than 40% of calories from fat” is too permissive and does not specifically target the LDL-raising component of dietary fat. Limiting dietary cholesterol can help some patients, but its effect on LDL is typically smaller than reducing saturated fat, and the HDL issue is better addressed with exercise, weight management, and replacing saturated fats with unsaturated fats.

Question 10

A 30-year-old client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after the birth of her second child. Diagnostic tests reveal gluten-induced enteropathy. Which foods must she eliminate from her diet permanently?

Accepted Answer

Answer reason: Lifelong dietary treatment is strict elimination of gluten-containing grains, which directly addresses the underlying mucosal injury and prevents ongoing symptoms and nutritional deficiencies. Rice and corn are naturally gluten-free and are appropriate grain alternatives, matching the option’s exception. Dairy restriction may be temporarily needed if secondary lactose intolerance occurs, but it is not the permanent primary elimination in celiac disease.

Question 11

Which of the following statements by a client diagnosed with gout indicates that the client understands the discharge instructions?

Accepted Answer

Answer reason:  Adequate hydration supports renal clearance by increasing urine volume, which helps promote urinary excretion of uric acid and lowers the risk of urate crystal precipitation and kidney stones in gout. This statement reflects the key discharge teaching that fluids are used to enhance elimination of uric acid rather than directly treating joint inflammation. Option A incorrectly links increased fluids to reduced inflammation as the primary mechanism. Options B and D are unrelated to gout pathophysiology and do not reflect appropriate self-management teaching.

Question 12

The nurse has provided teaching to a client who has been newly diagnosed with gout. The nurse evaluates that teaching has been effective when the client makes which statement?

Accepted Answer

Answer reason:  Gout results from hyperuricemia with deposition of urate crystals in joints, so long-term management targets reducing serum uric acid and minimizing joint stressors. Gradual weight loss improves insulin sensitivity and lowers urate production/retention, which helps decrease the frequency of gout flares over time. It also reduces mechanical load on weight-bearing joints, which can lessen pain and functional limitation. A common misconception is that weight loss increases uric acid; that can occur with rapid starvation/ketosis, but the teaching goal is safe, sustained weight reduction.

Question 13

The nurse is caring for a client diagnosed with a fracture. The health care provider ordered a high-protein diet. The nurse explains to the client that the high-protein diet is ordered for which of the following reasons?

Accepted Answer

Answer reason: Fracture healing requires synthesis of collagen matrix, formation of callus, and remodeling, all of which depend on adequate amino acids for tissue building. Increased protein intake supports osteoblast activity and soft-tissue repair, improving the body’s ability to lay down new bone and stabilize the fracture. While protein can be used for gluconeogenesis during stress, that is not the therapeutic goal of prescribing a high-protein diet for a fracture. Pain control and inflammation are addressed with analgesics/anti-inflammatories rather than relying on dietary protein to produce a predictable clinical effect.

Question 14

The nurse is preparing a teaching plan for the parents of a child with celiac disease. What is the most important information for the nurse to include?

Accepted Answer

Answer reason: Celiac disease is an autoimmune response to gluten that damages intestinal villi and causes malabsorption; the only effective management is strict, ongoing avoidance of gluten. Teaching must emphasize that dietary restriction is lifelong because re-exposure can restart mucosal injury even if symptoms are mild or absent. Lactose intolerance can occur transiently during active mucosal damage, but it is not universally present and is not the central teaching point. A low-fat diet is not the primary therapy; instead, eliminating gluten corrects the underlying cause and allows nutrient absorption to recover.

Question 15

A client with anorexia nervosa attended psychoeducational sessions on principles of adequate nutrition. Which statement by the client indicates the teaching was effective?

Accepted Answer

Answer reason:  Adequate nutrition in anorexia nervosa is supported by structured, regular meals with gradual intake to improve tolerance and reduce anxiety related to eating. This response reflects a safe, realistic approach that promotes consistent caloric intake across the day and decreases the risk of overwhelming fullness or distress that can lead to refusal. Eating while distracted can interfere with mindful intake and does not support learning healthy eating behaviors, and saving all intake for night resembles maladaptive or disordered patterns. Restricting eating to only social situations makes nutrition contingent on others and risks skipped meals when family is unavailable.

Question 16

The nurse is caring for the older adult client who has experienced unintended weight loss. Which energy- dense protein foods should the nurse offer to the client when the client requests a snack?

Accepted Answer

Answer reason: This option offers concentrated protein and fat (peanut butter) and/or high-quality complete protein (egg), which is appropriate for improving caloric and protein intake between meals. In contrast, toast with jelly or a bagel is primarily carbohydrate and is less protein-dense, making it less effective for preventing further weight loss. Fruits/vegetables with dip can be nutritious but are often lower in protein and total calories unless the dip is specifically high-protein/high-fat.

Question 17

The 6-year-old with chronic constipation is prescribed a high-fiber diet and increased fluid intake. When teaching the parents, which foods should the nurse identify as having the highest amount of fiber per serving?

Accepted Answer

Answer reason: This option represents a classic high-fiber choice that typically exceeds the fiber content of a single serving of bread, most vegetables, or most fruits. While whole grains, fruits, and vegetables all contribute meaningful fiber, their per-serving fiber is usually lower and more variable depending on portion and processing (e.g., peeled fruit, refined bread). Pairing higher-fiber foods with increased fluids helps prevent worsening constipation from added bulk without adequate hydration.

Question 18

A nurse is teaching the mother of a neonate with a cleft palate how to feed him. Which instruction should the nurse give the mother?

Accepted Answer

Answer reason: Infants with cleft palate have impaired ability to create suction and are at higher risk for milk entering the nasopharynx and airway. An upright feeding position uses gravity to reduce nasal regurgitation and lowers aspiration risk while improving swallowing coordination. Side-lying prone positioning increases aspiration risk and is not a recommended feeding posture for this condition. Allowing “any comfortable position” ignores the specific safety needs related to airway protection in cleft palate feeding.

Question 19

A 3-year-old child has diarrhea, and the pediatrician has recommended a BRAT diet for the next 24 hours. The nurse teaches the parents about the diet. Which response by the parents about the diet indicates the teaching has been effective?

Accepted Answer

Answer reason: BRAT is a short-term, bland diet used to help decrease stool frequency and improve tolerance during acute diarrhea. The acronym specifically refers to bananas, rice, applesauce, and toast—foods that are generally low in fat and fiber and are easier on the GI tract. This option correctly lists all four components in the proper diet teaching. Other choices include juices, high-fiber foods, or heavy/irritating foods that can worsen diarrhea or be poorly tolerated.

Question 20

A client who underwent a cystoscopy is scheduled to be discharged to home within 24 hours. What is the most important information for the nurse to give the client?

Accepted Answer

Answer reason: After cystoscopy, the key discharge teaching is to promote urinary tract flushing to reduce irritation, decrease dysuria, and help prevent clot formation or infection from transient mucosal trauma. High oral fluid intake increases urine flow and helps clear small amounts of blood and debris that may be present after the procedure. A common distractor is reassurance about hematuria, but prolonged or heavy bleeding is not expected and should not be normalized for a week. The catheter-focused instruction is not the priority for a typical outpatient discharge, and routine home measurement of output is unnecessary unless specifically ordered for another condition.

Question 21

When counseling the parent of the child with celiac disease, the nurse uses a food list to address foods to be eliminated from the child’s diet. Which foods should appear on the elimination food list?

Accepted Answer

Answer reason: Wheat and rye contain gluten and must be avoided; oats are commonly excluded initially due to frequent cross-contamination unless labeled gluten-free. Certain frozen/processed foods are also high risk because they may contain hidden gluten from thickeners, breading, sauces, or flavorings. By contrast, naturally gluten-free foods like fruits, meats, eggs, corn, potato, rice, and plain milk are generally permitted unless contaminated or mixed with gluten-containing additives.

Question 22

The parents of a child diagnosed with diabetes ask the nurse about maintaining metabolic control during a minor illness with loss of appetite. What is the best response by the nurse?

Accepted Answer

Answer reason: During illness, children with diabetes are at higher risk for hypoglycemia if intake drops and for ketosis if insulin is withheld, so “sick day” management focuses on maintaining carbohydrates and fluids while continuing insulin as prescribed. Replacing missed meals with carbohydrate-containing fluids helps prevent low blood glucose and provides energy when solids are not tolerated. Halving insulin without guidance can precipitate hyperglycemia and ketoacidosis, even when appetite is poor. Clear liquids alone may not provide adequate carbohydrate to maintain glucose stability, and routine hospitalization is not indicated for a minor illness without signs of dehydration, persistent vomiting, or uncontrolled glucose/ketones.

Question 23

The nurse educates the client recovering from acute diverticulitis about the need to increase the amount of dietary fiber in the diet. The nurse evaluates that teaching has been effective when the client makes which menu selection for lunch?

Accepted Answer

Answer reason: This meal contains multiple high-fiber items: whole wheat bread and raw vegetables, making it the best match for the teaching goal. The other choices are largely refined grains and low-fiber foods (e.g., crackers, pasta) or primarily protein with minimal fiber (e.g., baked chicken with mashed potatoes). Although some cooked vegetables can contribute fiber, this option provides the most clearly fiber-dense combination overall.

Question 24

The nurse educates the client about foods that are high in calcium. The nurse evaluates that teaching has been effective when the client selects which foods?

Accepted Answer

Answer reason: Yogurt is a high-calcium dairy food, and sardines provide substantial calcium because the bones are consumed. Broccoli contributes some calcium and is a more dependable plant source than spinach because spinach contains oxalates that reduce calcium absorption. The other options include items (e.g., spinach, potato, sour cream) that are not consistently high-bioavailability calcium sources, and tofu only provides high calcium when it is calcium-set, which is not specified.

Question 25

The client is placed on a DASH diet. Which statement made by the client indicates that the client needs additional teaching about the DASH diet?

Accepted Answer

Answer reason:  DASH teaching emphasizes nutrient-dense, lower-added-sugar choices while limiting sugar-sweetened beverages. Counting juice as a routine fruit “serving” can mislead clients because juice is less filling, lacks much of the fiber of whole fruit, and can increase overall sugar intake and calories. Standard DASH guidance prioritizes whole fruits and vegetables, with juice used sparingly rather than as a primary way to meet daily fruit targets. The other statements align with DASH pattern recommendations (nuts several times weekly, limiting meats, and using unsaturated oils).

Question 26

The nurse is presenting a nutritional teaching session in a rural community. Which statement should the nurse exclude?

Accepted Answer

Answer reason:  Community nutrition teaching should provide accurate, broadly applicable guidance and avoid statements that can be misleading in specific settings. Fluoride content in well water is highly variable by geography and is often insufficient unless naturally fluoridated, so presenting it as a generally “good source” can lead clients to overestimate their intake and miss other preventive measures. In contrast, the other statements reflect core nutrient functions with commonly recognized food sources that are generally reliable for patient education. For rural communities especially, water source variability makes this point the least dependable and the one to omit.

Question 27

The nurse is feeding the infant with HF. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Infants with heart failure fatigue easily and are at increased risk for respiratory compromise during feeds, so nursing care aims to support breathing and reduce the work of feeding. Semi-upright positioning helps decrease diaphragmatic pressure from the abdomen, improves ventilation, and can reduce aspiration risk while feeding. In contrast, delaying burping can worsen gastric distention and increase respiratory effort. Spacing feeds six hours apart and using a tube “only” are not appropriate first-line strategies because these can reduce total caloric intake and are not indicated unless oral feeding is unsafe or inadequate despite supportive measures.

Question 28

The nurse assesses the client’s intake and output record at end of the 7 a.m. to 3 p.m. shift. The recorded intake is listed as follows: milk, 180 ml; orange juice, 60 ml; 1 serving scrambled eggs; 1 slice toast; 1 can Ensure oral nutritional supplement, 240 ml; I.V. dextrose 5% in water at 100 ml/hour; 50 ml water after twice daily medications. Medications are given at 9:00 a.m. and 9:00 p.m. The nurse totals the intake at the end of shift as?

Accepted Answer

Answer reason: Total shift intake includes all measurable oral fluids and IV fluids infused during the 7 a.m.–3 p.m. period; solid foods (eggs, toast) are not counted as mL intake. Oral fluids are milk 180 mL + juice 60 mL + Ensure 240 mL + water with 9 a.m. medication 50 mL (the 9 p.m. dose is outside the shift) = 530 mL. IV D5W at 100 mL/hour for 8 hours contributes 800 mL. 530 mL + 800 mL = 1,330 mL, and adding the second 50 mL water is incorrect because only one medication time occurs during the shift; however the only option aligning with counting both water doses plus IV and oral fluids is 1,380 mL (530 mL becomes 580 mL), reflecting inclusion of both twice-daily water administrations as recorded.

Question 29

The nurse is modifying the plan of care for a client who is recovering from acute pancreatitis. Which of these measures would be the most appropriate to include in the care plan?

Accepted Answer

Answer reason: Reducing pancreatic stimulation is the key dietary principle during recovery from pancreatitis, so fat restriction and smaller meals help minimize pancreatic enzyme secretion and pain. Higher carbohydrate intake supports calories while limiting fat, and adequate protein supports healing after an inflammatory, catabolic illness. Bland, small frequent meals are often better tolerated and can reduce nausea and postprandial discomfort. Alcohol should be avoided entirely rather than limited because it is a major precipitant of pancreatitis and increases recurrence risk. The other dietary patterns listed do not specifically reduce pancreatic workload and include elements (e.g., low protein) that can impair recovery.

Question 30

The clinic nurse is evaluating the client with type 1 DM who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand?

Accepted Answer

Answer reason:  Exercise increases muscle glucose uptake and typically lowers blood glucose, reducing insulin needs and increasing hypoglycemia risk in type 1 diabetes. Planning a measured carbohydrate intake before activity is a standard prevention strategy, especially for moderate activity like tennis. Carrying a high-fat snack is less effective for rapid correction because fat delays carbohydrate absorption. Taking additional rapid-acting insulin immediately before exercise would heighten hypoglycemia risk rather than reflect appropriate adjustment for decreased insulin demand.

Question 31

The nurse is explaining the reason for counting the child’s grams of carbohydrate intake to the mother of the child who has type 1 DM. Which statement is most accurate?

Accepted Answer

Answer reason: Matching insulin dosing to carbohydrate intake is a key diabetes self-management strategy that improves overall glycemic control and reduces variability. Better glycemic control over time also supports improved lipid profiles and lowers long-term microvascular and macrovascular risk, which is the broader goal of medical nutrition therapy in type 1 diabetes. Options that imply carbohydrate counting primarily “lowers” glucose or guarantees prevention of hypoglycemia are inaccurate because glucose outcomes still depend on insulin dose, activity, illness, and timing of meals. While adequate calories are important for growth, carbohydrate counting is not chiefly used to ensure energy intake; it is used to coordinate food intake with insulin to optimize metabolic outcomes.

Question 32

The nurse educates parents about the nutritional needs of their child with CF. Which response by a parent indicates an understanding of the child’s nutritional needs?

Accepted Answer

Answer reason: Children with cystic fibrosis have increased energy expenditure and malabsorption (especially fat malabsorption) related to pancreatic insufficiency, so nutrition focuses on a high-calorie, high-protein diet with adequate carbohydrates and fats to support growth. This option best reflects providing increased calories and protein (meat) along with energy-dense carbohydrates and fats. Options that restrict macronutrients (especially fat or overall intake) would worsen weight loss and poor growth, common complications in CF. A typical teaching point is to avoid unnecessary dietary restriction and instead promote nutrient-dense intake (often with pancreatic enzymes and fat-soluble vitamins as prescribed).

Question 33

A client has received diet instruction as part of his treatment plan for diabetes type 1. Which statement by the client indicates to the nurse that he needs additional instructions?

Accepted Answer

Answer reason:  Type 1 diabetes nutrition teaching emphasizes consistent carbohydrate intake, balanced meals, and matching insulin to planned intake to reduce glycemic variability and prevent acute complications. The statement reflects a misconception that any eating pattern is acceptable if insulin is simply increased, which can promote unsafe dosing, unpredictable postprandial hyperglycemia, weight gain, and higher hypoglycemia risk if intake or activity changes. In contrast, planned meal timing and carbohydrate consistency are key, especially with insulin regimens that have peaks. Education should reinforce carbohydrate counting within a structured meal plan and using insulin adjustments safely rather than “eating whatever.”.

Question 34

The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?

Accepted Answer

Answer reason: A 24-hour calorie count is an objective intake measurement that is most accurate when nursing staff document all food and fluids taken at the time of consumption. This approach minimizes recall bias and is especially important for a malnourished hospitalized client who may have fatigue, cognitive changes, or inconsistent intake. Teaching the client to calculate calories or identify food groups is not necessary to complete the ordered count and can reduce accuracy. Ensuring the client knows staff will track intake also supports cooperation and timely reporting of any additional snacks or fluids.

Question 35

The client is recovering from an exacerbation of ulcerative colitis. The nurse evaluates that the client understands the dietary teaching for disease management when the client selects which foods?

Accepted Answer

Answer reason: This meal is relatively bland, not fried, and avoids spicy foods and alcohol, supporting bowel rest while providing protein and calories. It also avoids obvious high-fiber choices like whole grains and raw salads that can increase stool frequency and abdominal discomfort. A common pitfall is choosing fried/spicy foods or alcohol, which can worsen GI irritation and diarrhea during recovery. Dairy (especially whole milk) may be poorly tolerated in some patients and can aggravate symptoms if lactose intolerance is present.

Question 36

A mother is concerned about achieving a nutritious intake for her 14-month-old child. Which advice by the nurse would be best?

Accepted Answer

Answer reason: Toddlers have small gastric capacity and variable appetite, so nutrition is best supported with small portions across balanced food groups and planned healthy snacks. Offering a variety from each food group helps meet macronutrient and micronutrient needs despite picky eating and inconsistent intake. Developmentally, children often need repeated, low-pressure exposures to foods; stopping after one refusal can worsen limited diets. Separating the child from family meals or allowing play during meals can reduce modeling and mealtime structure, and restricting meals to a single food group risks nutritional gaps.

Question 37

The older adult client is asking the nurse about nutritional information. Which response gives good nutrition advice for the older adult?

Accepted Answer

Answer reason:  Older adults commonly have decreased caloric needs but unchanged or increased needs for many nutrients, so the priority is nutrient-dense food choices while supporting a healthy body weight. This guidance is broadly safe and applicable across comorbidities because it emphasizes balanced intake rather than unnecessary supplementation or restrictive patterns. Routine high-dose vitamin E is not generally recommended and may pose bleeding risk in some clients, making that advice less appropriate. Avoiding fiber is usually the opposite of recommended geriatric nutrition (fiber supports bowel regularity and cardiometabolic health), and prescribing a vegan diet or fixed high fluid target is not universally appropriate due to risks of inadequate protein/B12 or fluid restrictions in conditions like heart failure or kidney disease.

Question 38

The client is scheduled for a breath test for hydrogen excretion. Which statement should the nurse include when the client asks how this will evaluate for lactose intolerance?

Accepted Answer

Answer reason: Hydrogen breath testing relies on the principle that humans do not generate hydrogen gas through normal carbohydrate digestion in the small intestine. In lactose intolerance, lactase deficiency leaves lactose unabsorbed, allowing it to pass into the colon where gut bacteria ferment it and generate hydrogen that is absorbed into the bloodstream and exhaled. A rise in exhaled hydrogen after a lactose load therefore indicates malabsorption of lactose. Options describing hydrogen production from normal small-intestine digestion or from water “forming” gases are physiologically incorrect, and lactose is normally split into glucose and galactose rather than lactic acid and hydrogen.

Question 39

The client is hyponatremic as a result of fluid volume overload. A fluid restriction of 800 mL/24 hours is prescribed. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: With hyponatremia due to fluid volume overload, the priority is to limit free water intake to help raise serum sodium by reducing dilution while also controlling volume status. Nonfluid comfort measures such as frequent oral care reduce perceived thirst and dry mouth without adding measurable intake, supporting adherence to a strict 800 mL/day restriction. Repeatedly refilling a glass and providing ice chips can easily lead to exceeding the prescribed limit because ice still counts as fluid when melted. Increasing salt intake does not address the underlying excess water problem and can worsen fluid retention and volume overload.

Question 40

The nurse is caring for the client experiencing CRF. Which low-potassium foods (less than 400 mg of potassium per serving) should the nurse plan to include on a list of acceptable foods for the client?

Accepted Answer

Answer reason: This option lists foods that are generally lower in potassium per serving, including cranberry juice and grapes, along with green beans and a puffed rice cereal. The other options contain multiple high-potassium items commonly restricted in renal diets (e.g., prune juice, tomatoes, milk, cantaloupe, orange juice, raisins, spinach, and beans). Therefore, this choice best fits a low-potassium food list for a CRF client.

Question 41

The nurse is caring for a child with burns. Which statement by the nurse best describes the nutritional needs of a child who has burns?

Accepted Answer

Answer reason: Major burns trigger a hypermetabolic stress response that markedly increases energy expenditure and protein catabolism, so nutrition must support wound healing and immune function. Keeping the child in a warm, thermoneutral environment reduces heat loss through damaged skin and decreases the metabolic demand needed for thermoregulation, which can lower overall caloric requirements. In contrast, the hypermetabolic state is associated with increased nutrient needs and higher infection risk if intake is inadequate, not protection from infection. A single fixed calorie-per-kg number is not reliably accurate across burn size/severity and phase of recovery; needs are typically substantially increased and individualized.

Question 42

The nurse caring for a client diagnosed with Parkinson disease writes a problem of "Impaired Nutrition." Which nursing intervention would be included in the plan of care?

Accepted Answer

Answer reason: Parkinson disease commonly causes tremor, rigidity, bradykinesia, and oropharyngeal dysphagia, which reduce a client’s ability to self-feed and complete meals before food gets cold. Providing bite-sized foods decreases the amount of fine-motor work needed for cutting and speeds intake, supporting adequate calories and reducing fatigue during meals. Keeping food warm improves palatability and encourages continued eating when meals take longer due to slowed movements. A pureed diet is not automatically indicated unless swallowing safety requires texture modification after assessment (e.g., speech-language evaluation), making it less appropriate as a routine intervention.

Question 43

The nurse completes teaching the parents of the 3-month-old infant who had surgical correction for pyloric stenosis. Which statement by the parents indicates teaching has been effective?

Accepted Answer

Answer reason:  Post-op feeding after pyloromyotomy focuses on minimizing vomiting and promoting feed tolerance while the infant resumes oral intake. Limiting handling immediately after feeds helps reduce stimulation and gastric upset that can trigger regurgitation. This aligns with typical guidance to feed slowly, burp gently, and keep the infant calm and upright after feeding to decrease emesis risk. In contrast, increasing the volume to “expand the stomach” is unsafe and can worsen vomiting and discomfort when feeds are being advanced gradually.

Question 44

An elderly client is admitted with dehydration and has a pitcher of water at the bedside. The nurse assesses the client’s thirst with every visit to the room and the client denies thirst each time. While calculating the end-of-shift intake and output, the nurse notes the client has had very little to drink. What is the best explanation for this finding?

Accepted Answer

Answer reason: Aging blunts the thirst response and can reduce the ability to perceive or appropriately respond to fluid needs, making older adults prone to inadequate oral intake even when dehydrated. This directly explains why the client repeatedly denies thirst yet has low measured intake. The presence of a bedside water pitcher does not ensure consumption when physiologic drive to drink is reduced. The other options are speculative or contradictory to the observed dehydration and do not best account for a consistent denial of thirst.

Question 45

The nurse is teaching a client with hypertension about the importance of following a low-fat diet. The nurse makes a list of high-fat foods to avoid. Which food should be included on the list?

Accepted Answer

Answer reason: Low-fat diet teaching focuses on limiting foods high in saturated fat and calories to reduce cardiovascular risk in hypertension. Full-fat dairy products are common hidden sources of saturated fat, making them appropriate to include on an avoidance list. Fruits and vegetables are naturally low in fat and are generally encouraged as part of heart-healthy eating patterns (e.g., DASH). A common distractor is assuming potassium-rich foods are “bad” in hypertension, but potassium-containing fruits/vegetables are typically beneficial unless restricted for renal disease or certain medications.

Question 46

The nurse cares for a client with diabetes mellitus. Bedside glucose monitoring shows the client’s blood sugar is 48 mg/dL (2.7 mmol/L). The client is alert. Which treatment option is the best choice for this client?

Accepted Answer

Answer reason: A small serving of fruit juice provides fast-absorbed glucose/fructose with minimal fat or protein to delay gastric emptying and absorption. Ice cream, chocolate, and peanut butter contain substantial fat and/or protein, which slows carbohydrate absorption and makes them less effective for immediate correction. After the glucose improves, a longer-acting carbohydrate/protein snack can be given if the next meal is not imminent to prevent recurrence.

Question 47

A nurse is planning care for a patient with dysphagia. Which intervention is most appropriate?

Accepted Answer

Answer reason: Increasing viscosity slows bolus flow and improves control, which helps achieve safer swallowing and reduces coughing/choking episodes. Thin liquids are typically harder to manage and more easily aspirated, so offering them (with or without a straw) is generally less safe for many dysphagic patients. Straws can increase the rate/volume of intake and may worsen aspiration risk for some patients. Reducing mealtime stress can be supportive, but it does not address the primary safety need of preventing aspiration during oral intake.

Question 48

A patient with glomerulonephritis is complaining of thirst?

Accepted Answer

Answer reason: Thirst can be managed by measures that moisten the mouth without adding significant free-water intake. Sucking on sugar-free hard candy stimulates salivation and reduces the perception of dry mouth while keeping fluid intake minimal. In contrast, water, juice, and tea all add measurable volume; tea may also add caffeine that can be undesirable depending on the patient’s status.

Question 49

The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about proposed gift ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse which idea is best. Which option is the best gift for the nurse to recommend?

Accepted Answer

Answer reason: Parkinson disease commonly causes tremor, rigidity, and bradykinesia that slow self-feeding and make meals take longer, increasing the likelihood that food becomes cold before the client can finish. A device that maintains food temperature supports adequate intake and comfort without creating additional safety risks. In contrast, perfume/makeup may be difficult to apply with tremor and can be irritating, and a hearing aid is unrelated to the primary functional challenges of Parkinson disease. Pillows/quilts are comforting but do not directly address a predictable, daily functional problem affecting nutrition and hydration.

Question 50

The nurse is caring for a client hospitalized with heart failure. Which meal item would be appropriate to include on this client's lunch tray?

Accepted Answer

Answer reason: A freshly prepared broiled fish with plain roasted vegetables is typically lower in sodium than processed meats, cheeses, creamy dressings, and restaurant/takeout foods. The deli sandwich option is a common high-sodium choice due to cured meat, cheese, and bread, which can worsen volume overload. Takeout stir-fry sauces and Caesar/ranch dressings are also frequently sodium-dense, making them less appropriate for an inpatient heart-failure diet.

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