Question 1

The client taking lithium for treatment of a bipolar disorder is concerned that the medication is becoming less effective in controlling symptoms. It is most important for the nurse to question the client’s intake of which nutrient?

Accepted Answer

Answer reason: Increased sodium intake promotes renal excretion of lithium, which can lower lithium concentrations and make the medication seem less effective. Conversely, low sodium intake or dehydration can increase lithium levels and raise toxicity risk, so assessing sodium intake is a key safety and effectiveness check. The other nutrients listed do not have the same direct, clinically important effect on lithium clearance and therapeutic levels.

Question 2

A dietary aide shows the nurse the snack options for the client on a clear liquid diet. Which selection should the nurse eliminate from the snack choices?

Accepted Answer

Answer reason: Milk is not considered a clear liquid because it is opaque and contains fat/protein that can increase gastric residue and potentially worsen nausea or intolerance. Gelatin, iced tea, and apple juice are typical clear-liquid choices because they are transparent and easily digested. A common pitfall is confusing “liquid” with “clear liquid”; dairy belongs to full-liquid diets, not clear-liquid diets.

Question 3

A client has just had a nasogastric tube placed. What is the best method for verifying correct placement of the tube in the stomach?

Accepted Answer

Answer reason: Initial NG tube placement must be confirmed with the most definitive method to prevent catastrophic complications such as pulmonary placement and aspiration. Radiographic confirmation visualizes the tube’s course and tip location, making it the gold standard immediately after insertion before using the tube for feeding or medications. Bedside checks like aspirate pH can support ongoing verification but are less reliable initially due to factors like acid-suppressing therapy or inability to obtain aspirate. Auscultation of an air bolus (“whoosh test”) and checking external markings are not reliable indicators of gastric placement and can give false reassurance.

Question 4

Which statement by a client who had nasal surgery indicates to the nurse that the client needs further teaching about postoperative care?

Accepted Answer

Answer reason: " After nasal surgery, teaching focuses on preventing bleeding and avoiding actions that increase pressure or irritate healing tissues, while also preventing constipation and straining. Bananas can be constipating for some clients, which may increase the risk of Valsalva/straining during bowel movements and thereby increase postoperative bleeding risk. Frequent mouth care is appropriate because mouth breathing and nasal packing cause dryness, and maintaining adequate fluids helps keep secretions thin and supports healing. A vitamin C–rich food choice such as oranges is generally reasonable to support tissue repair and does not directly increase bleeding risk.

Question 5

The nurse is caring for the pediatric client with hyperthyroidism. Which intervention would the nurse plan to include in the child's plan of care?

Accepted Answer

Answer reason: Hyperthyroidism raises metabolic rate, leading to weight loss, increased energy expenditure, and often increased appetite, so nutritional support with higher calorie intake is a key nursing intervention. This helps prevent malnutrition and supports growth needs in a pediatric client. Warming the room is inappropriate because heat intolerance and diaphoresis are common, and a cooler environment is typically better tolerated. Increasing physical activity can worsen tachycardia, fatigue, and catabolism, and extra salt is not a standard therapeutic measure for hyperthyroidism.

Question 6

The nurse is caring for a child with celiac disease who has been started on the prescribed diet. The nurse expects that 1 or 2 days after starting the diet the child will have which of the following?

Accepted Answer

Answer reason: A rapid return of hunger is a common early improvement once abdominal discomfort and malabsorption-related nausea lessen. Diarrhea and foul-smelling stools are characteristic of untreated malabsorption and should gradually improve rather than newly appear after starting the diet. Weight gain (not loss) is expected over time as absorption normalizes.

Question 7

Which nursing intervention will help prevent vomiting in an infant diagnosed with pyloric stenosis?

Accepted Answer

Answer reason: Pyloric stenosis causes gastric outlet obstruction with forceful peristalsis, so stimulation and movement after feeds can trigger or worsen emesis. Limiting handling reduces gastric agitation and decreases the likelihood of vomiting episodes. Large, spaced-out feeds increase gastric distention and typically worsen vomiting rather than prevent it. Prone positioning is not a primary vomiting-prevention strategy and may introduce safety concerns in infants if not closely monitored.

Question 8

When teaching an adolescent with iron deficiency anemia about diet choices, which menu selection would indicate that more instruction is necessary?

Accepted Answer

Answer reason: This menu is largely low in iron density and provides minimal high-quality iron sources compared with meals containing meat, beans, eggs, or nuts. A common pitfall is choosing “light” foods that do not meaningfully increase iron intake despite seeming healthy. The other options each include more iron-rich components (beef/sausage, beans, eggs, peanuts), making them more appropriate choices for improving iron status.

Question 9

The nurse is devising a meal plan for a child newly diagnosed with celiac disease. Which menu choices best meets the child’s needs?

Accepted Answer

Answer reason: This menu is the best fit because it can be gluten-free when the hamburger is served without a wheat bun and the sides/drink are naturally gluten-free, making it the safest overall choice. The other menus clearly center on gluten-containing foods such as pizza crust, breaded nuggets, pasta, and brownies, which commonly contain wheat flour. For a newly diagnosed child, selecting an option that most easily avoids obvious gluten sources supports symptom control and intestinal healing while still providing calories and protein.

Question 10

A client is given instructions for a low-sodium diet. Which statement best shows the nurse that the client understands the diet instruction?

Accepted Answer

Answer reason: Low-sodium teaching focuses on identifying common dietary sources of sodium so the client can limit intake to reduce fluid retention and blood pressure. Many animal protein foods and especially processed or cured varieties (eg, deli meats, canned meats, smoked fish, injected/seasoned poultry) can contain substantial sodium, so recognizing this category as a sodium source reflects appropriate understanding. Fruits are generally low in sodium and do not need to be avoided, making that statement inconsistent with the diet. Restaurant meals are typically high in sodium due to seasoning and processed ingredients, so increasing restaurant eating would work against the goal.

Question 11

The client has xerostomia secondary to oxybutynin use for treating urge incontinence. Which interventions should the nurse implement to relieve xerostomia?

Accepted Answer

Answer reason: Anticholinergic medications like oxybutynin reduce salivary gland secretion, so symptom relief focuses on stimulating saliva and maintaining oral moisture. Sugar-free lozenges or gum increase salivary flow through gustatory and mechanical stimulation while avoiding added caries risk that comes with sugary products in a dry mouth. Measures aimed at skin comfort (tepid bathing, lotion) do not address oral dryness. A fan can worsen dryness by increasing evaporation from mucous membranes, potentially intensifying symptoms.

Question 12

The client telephones the clinic after having 3 days of symptoms that strongly suggest influenza. What should the nurse advise?

Accepted Answer

Answer reason: Influenza management for an otherwise stable caller is primarily supportive, focusing on reducing dehydration risk, maintaining mucosal hydration, and promoting recovery. Adequate oral fluids and rest address common flu-related fever, tachypnea, and decreased intake that can quickly lead to fluid deficit and worsening fatigue. Antihistamines do not treat influenza and can cause drying and sedation, potentially worsening symptoms. A flu shot is preventive and is not used as treatment once symptoms are established; return-to-work advice is unsafe without ensuring symptom improvement and decreased contagiousness.

Question 13

The client who is African American is breastfeeding her infant. The infant has lactose intolerance. The mother shows the nurse a list of foods that she has been eating- What food should the nurse advise the mother to avoid?

Accepted Answer

Answer reason: In a breastfeeding dyad, maternal intake of lactose-containing dairy can contribute to infant gastrointestinal symptoms in some cases, so the nursing teaching focuses on eliminating obvious dietary lactose sources first. This option is a dairy product and therefore the most relevant item to avoid compared with grains, vegetables, or fruit, which do not contain lactose. The other choices are non-dairy foods and would not be expected to worsen lactose-related symptoms.

Question 14

A client newly diagnosed with diverticulosis is being discharged. The client asks the nurse what type of diet may have contributed to the diagnosis. What is the best response by the nurse?

Accepted Answer

Answer reason: Low fiber reduces stool volume and slows colonic transit, promoting harder stools and straining that can contribute to formation of diverticula. Increasing dietary fiber is a standard preventive strategy to improve stool consistency and decrease pressure in the colon. A high-fiber pattern is generally protective rather than causative, making it a common distractor.

Question 15

A nurse is providing nutritional teaching for a client with a family history of colon cancer. Which dietary choice by the client demonstrates understanding of the appropriate diet to follow?

Accepted Answer

Answer reason: This choice is plant-based and typically rich in beans and vegetables, supporting bowel health and dilution/shorter transit time of potential carcinogens. Processed meats (e.g., hot dogs) are associated with increased colorectal cancer risk and are an important avoid/limit teaching point. Meat-based options also tend to increase saturated fat and reduce fiber density compared with a bean/vegetable-based meal.

Question 16

The nurse is developing a dietary care plan for a client diagnosed with microcytic anemia. Which foods, if selected by the client, would indicate to the nurse that teaching was effective?

Accepted Answer

Answer reason: This meal provides heme iron from ham and additional non-heme iron from peas/legumes, supporting hemoglobin synthesis. In contrast, hot tea contains tannins that inhibit iron absorption, making that choice inconsistent with effective dietary teaching. While other options contain some nutrients, they are generally less iron-dense than a legume-plus-meat combination for building iron stores.

Question 17

A high-protein diet is ordered for a client recovering from a fracture. The nurse explains to the client that which of the following is the reason for this diet?

Accepted Answer

Answer reason: Fracture healing requires increased protein for collagen synthesis, osteoid matrix formation, and overall tissue repair. Adequate amino acids support fibroblast proliferation and callus formation, which are essential steps toward stable union. While protein can be used for gluconeogenesis, that is not the primary therapeutic goal in fracture recovery. High protein intake also does not directly reduce analgesic needs or act as a primary anti-inflammatory treatment compared with appropriate medications and rest.

Question 18

The nurse determines further teaching is not needed when the mother of a child with celiac disease makes which statement?

Accepted Answer

Answer reason: Celiac disease requires lifelong strict gluten avoidance to prevent immune-mediated intestinal injury and malabsorption. Wheat, rye, and barley contain gluten and must be eliminated, and oats are commonly avoided unless specifically labeled gluten-free due to frequent cross-contamination. The other statements reflect unsafe teaching: a high-gluten diet worsens disease, potatoes/rice/corn are naturally gluten-free staples, and packaged/frozen foods can contain hidden gluten or cross-contamination and must be verified by label.

Question 19

Which goal is most important when teaching the parents of a child diagnosed with celiac disease?

Accepted Answer

Answer reason: The core principle in celiac disease management is strict, lifelong elimination of gluten to stop immune-mediated intestinal injury and restore nutrient absorption. Teaching must prioritize enabling the family to implement and sustain the gluten-free diet (including label reading and avoiding cross-contamination) because this is the intervention that prevents ongoing diarrhea, abdominal pain, weight/growth failure, anemia, and long-term complications. Psychosocial goals like maintaining normalcy and peer support are helpful, but they are secondary to controlling the underlying trigger that drives symptoms and malabsorption. Infection prevention is not the primary teaching focus for celiac disease compared with dietary adherence and monitoring growth and nutritional status.

Question 20

The pediatric unit has just been notified that they will be admitting an infant with cleft lip and palate. What is the best nursing intervention to implement when feeding the infant?

Accepted Answer

Answer reason: Infants with cleft lip/palate have impaired suction and an ineffective oral seal, which leads to increased air swallowing during feeds. Frequent burping helps reduce gastric distention, discomfort, and regurgitation risk, supporting safer, more effective feeding and improved intake. Limiting intake can worsen growth and does not address the feeding mechanics problem. Loud noises commonly reflect air leak/poor seal; pausing may help, but frequent burping is the most broadly appropriate, routine intervention across feeding attempts.

Question 21

Which nursing measure is helpful when mouth ulcers develop as an adverse effect of chemotherapy?

Accepted Answer

Answer reason: Soft, moist, bland foods reduce trauma to ulcerated tissues and help the child tolerate oral nutrition and hydration, supporting healing and preventing weight loss/dehydration. Acidic or drying agents can worsen discomfort and mucosal injury; lemon-glycerin swabs can be irritating and drying. Full-strength hydrogen peroxide is caustic to oral tissues and can delay healing, so it is avoided in favor of gentle oral care.

Question 22

Which nursing intervention helps to decrease the adverse effects of radiation therapy on the GI tract?

Accepted Answer

Answer reason: Providing adequate oral fluids supports hydration and helps prevent volume depletion from diarrhea or reduced intake. A soft, bland diet reduces mechanical and chemical irritation to inflamed GI lining and is typically better tolerated, which can lessen symptom burden. By contrast, treating nausea only after it occurs is reactive rather than preventing broader GI irritation and hydration problems. Mouthwash avoidance addresses oral mucositis care rather than GI-tract adverse effects from radiation.

Question 23

The nurse is caring for the client with a history of chronic alcoholism. Which observation should prompt the nurse to assess for a magnesium deficiency?

Accepted Answer

Answer reason: Chronic alcoholism commonly leads to hypomagnesemia from poor intake, GI losses, and renal wasting, so subtle early neuromuscular findings are important cues. Fasciculations (fine, flickerlike movements under the skin) are consistent with this hyperexcitability picture. In contrast, absent deep tendon reflexes and flaccid weakness are more typical of conditions that decrease neuromuscular excitability rather than increase it. Bowel sound changes are nonspecific and do not point as directly to magnesium deficiency as fasciculations/tetany-type findings.

Question 24

The nurse is planning a nutrition session during a health fair. Which food choices should the nurse include when teaching about omega-3 fatty acids?

Accepted Answer

Answer reason: Fatty fish such as salmon, mackerel, sardines, and trout are concentrated sources, and recommending intake at least twice weekly aligns with common preventive nutrition counseling. Leafy greens provide many micronutrients but are not primary omega-3 sources compared with fish. Cheese is not an omega-3–rich food, and “cholesterol-free” margarine does not reliably indicate omega-3 content and may primarily reflect processed fats rather than omega-3s.

Question 25

The nurse is counseling the client placed on a DASH diet who has limited food refrigeration capabilities and prefers using canned vegetables. Which nutrient excess should the nurse caution the client about when eating mainly canned, rather than fresh, vegetables?

Accepted Answer

Answer reason: Canned vegetables are commonly preserved with added salt, making sodium the most likely nutrient to become excessive when they are used as a primary vegetable source. Excess dietary sodium increases fluid retention and vascular resistance, counteracting the intended antihypertensive benefits of the DASH plan. Vitamins A and C are not typically increased by canning, and vitamin C is often reduced with processing and storage, making them less plausible excess concerns.

Question 26

The nurse is assessing a client during a home health visit. The client complains of severe burning on urination. What is the most important information for the nurse to give the client?

Accepted Answer

Answer reason: With dysuria suggestive of a urinary tract irritation/infection, the highest-priority self-care teaching is to increase oral fluids to promote urine dilution and frequent bladder emptying, which helps flush bacteria and reduces urinary concentration that worsens burning. This intervention is broadly safe for most clients and directly targets the symptom and potential cause. Cranberry juice may have a limited preventive role in some cases but is not as reliably therapeutic and can add sugar/acid that may irritate. Avoiding carbonated beverages and sitz baths can be helpful comfort measures, but they are secondary to adequate hydration for symptom relief and risk reduction.

Question 27

The nurse is caring for an 11-year-old client with cerebral palsy who has a pressure ulcer on the sacrum. When teaching the client's mother about dietary intake, which foods should the nurse plan to emphasize?

Accepted Answer

Answer reason: This option emphasizes high-biologic-value protein sources, which are most directly tied to improving wound healing and maintaining lean body mass in a child with limited mobility. Whole grains and fruits/vegetables contribute fiber and micronutrients but do not address the primary macronutrient need for pressure-injury recovery. Compared with legumes and cheese, this pairing more consistently provides complete proteins while limiting excess saturated fat that may come with higher-fat dairy choices.

Question 28

Which menu selection indicates to the nurse the client diagnosed with atherosclerosis understands the teaching concerning a low-fat, low-cholesterol diet?

Accepted Answer

Answer reason: A low-fat, low-cholesterol diet emphasizes lean proteins prepared without added fats, high-fiber whole grains, and plenty of fruits/vegetables to help reduce LDL and overall cardiovascular risk. This meal uses a cooking method that avoids frying and pairs it with whole grains and vegetables, which aligns with heart-healthy dietary teaching. The other choices include fried foods, processed meats, cheese, whole milk, and typical fast-food items that are higher in saturated fat and cholesterol and therefore conflict with dietary goals. This selection best reflects understanding of nutrition teaching for atherosclerosis management.

Question 29

When teaching a newly diagnosed diabetic client about diet and exercise, what is the most important information for the nurse to provide?

Accepted Answer

Answer reason: Emphasizing consistent carbohydrate intake, realistic dietary targets, and a sustainable activity plan helps prevent both hyperglycemia and exercise-related hypoglycemia. Exercise typically lowers glucose by increasing insulin sensitivity and muscle uptake, making the opposite claim unsafe. Advising calorie reduction before exercise can increase hypoglycemia risk, especially if medications are used, and does not address the core need for balanced, consistent meal planning alongside activity.

Question 30

An attack of pancreatitis has been brought on by gallstones and gallbladder disease. The client will require reinforcement about the need to follow which type of diet?

Accepted Answer

Answer reason: A low-fat diet reduces cholecystokinin-driven pancreatic stimulation and decreases biliary/pancreatic duct irritation, helping prevent recurrence after an acute episode. Smaller, lighter meals further limit postprandial pancreatic workload and can reduce pain and nausea. Higher-calorie/high-protein plans may be used later for nutritional repletion, but they do not directly address the key trigger of fat-induced pancreatic stimulation in biliary pancreatitis.

Question 31

The nurse is providing education about sick-day rules to a group of clients with type 1 diabetes mellitus. Which of the following information is appropriate to include?

Accepted Answer

Answer reason: During illness, clients with type 1 diabetes are at high risk for dehydration and diabetic ketoacidosis because stress hormones increase insulin needs and promote hyperglycemia with osmotic diuresis. Encouraging regular fluid intake helps prevent volume depletion and supports clearance of excess glucose/ketones. Sick-day teaching also emphasizes more frequent glucose/ketone monitoring and continuing insulin (often with dose adjustments), so advice like taking glucose only once daily or holding insulin is unsafe. Stopping all oral intake when nauseated increases dehydration risk; instead, clients should take small sips of fluids and seek care if unable to keep fluids down or if ketones are present.

Question 32

A client with newly diagnosed diabetes mellitus is ready for discharge. What is the most important information for the nurse to include?

Accepted Answer

Answer reason: Teaching how these three factors interact supports safe day-to-day decisions such as meal planning, activity adjustments, glucose monitoring, and when to treat lows. A high-calorie diet is not generally indicated and, while foot care is important, it is not the most foundational discharge priority compared with glycemic control skills. Avoiding all carbohydrates is unsafe and unrealistic; consistent carbohydrate intake and individualized nutrition planning are standard. Routine “fasting before maintenance visits” is not universally required and does not address immediate self-care needs after diagnosis.

Question 33

The nurse is teaching the client who lacks parathyroid hormone (PTH) about foods to consume. Which items should be included on a list of appropriate foods for the client?

Accepted Answer

Answer reason: Dark green vegetables, soybeans, and tofu are reliable calcium-containing foods that can help support serum calcium levels in this setting. A key pitfall is recommending high-oxalate foods because oxalates bind calcium in the gut and reduce absorption. Options that include spinach or rhubarb are less appropriate because these can impair calcium bioavailability despite being plant foods.

Question 34

The nurse is caring for the client who had a vertical banded gastroplasty. The nurse teaches that nausea can occur after this surgery from which situation?

Accepted Answer

Answer reason: After restrictive bariatric surgery, the reduced gastric pouch volume makes patients prone to nausea and vomiting when intake exceeds pouch capacity or occurs too quickly. Overfilling increases intragastric pressure and triggers nausea, often accompanied by discomfort and possible regurgitation, which is why teaching emphasizes small bites, slow eating, and stopping at the first sign of fullness. Vertical banded gastroplasty does not involve a duodenal incision, so duodenal inflammation is not an expected mechanism. Dumping syndrome is classically associated with rapid gastric emptying after procedures that bypass or significantly alter pyloric function and is more linked to high-carbohydrate meals rather than high-protein meals.

Question 35

The NA reports to the nurse that urine in the client’s urostomy bag is dark amber colored with a large amount of thick mucus. Which should be the nurse’s instruction to the NA?

Accepted Answer

Answer reason: Dark amber urine most commonly indicates concentrated urine from inadequate hydration, and urostomies (often created from an ileal segment) normally produce mucus that can appear thick. Increasing oral fluids is an appropriate first nursing assistant-level intervention to help dilute urine and reduce mucus thickness/plugging risk. A urine culture is not indicated based on color and mucus alone without infection signs (e.g., fever, foul odor, suprapubic pain, altered mental status). Changing the bag or ambulating does not address the likely cause and would not be the priority instruction for this finding.

Question 36

The nurse is planning care for the 18-month-old with iron-deficiency anemia. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Excessive cow’s milk intake in toddlers can contribute to iron-deficiency anemia by displacing iron-rich foods and reducing overall dietary iron intake. Implementing a limit supports improved nutritional balance and helps promote adequate iron consumption from foods and supplements. Macrocytosis is more consistent with folate or vitamin B12 deficiency, not iron deficiency, which typically causes microcytosis. Iron absorption is enhanced by vitamin C rather than vitamin D, and dark stools are an expected effect of oral iron; constipation can occur but does not require routine provider notification unless severe or accompanied by concerning symptoms.

Question 37

A client presents to the clinic for a follow-up appointment after diagnostic tests show he has gastroesophageal reflux disease. Which instruction should the nurse provide?

Accepted Answer

Answer reason:  GERD management focuses on reducing lower esophageal sphincter relaxation and minimizing triggers that increase reflux and esophageal irritation. Alcohol and caffeine commonly decrease sphincter tone and can worsen heartburn symptoms, so avoidance is a key lifestyle instruction. In contrast, lying down after meals promotes reflux by using gravity against gastric emptying and is contraindicated. Large fluid volumes with meals and simply eating three standard meals do not directly target reflux triggers and may worsen symptoms if they increase gastric distention.

Question 38

A nurse should include which information on nutrition when teaching the family of a child with cystic fibrosis?

Accepted Answer

Answer reason: Children with cystic fibrosis have increased energy expenditure from chronic respiratory work and frequent infections, plus malabsorption related to pancreatic insufficiency. A high-calorie, high-protein diet helps prevent failure to thrive and supports growth and immune function. Fluid restriction is not appropriate because hydration helps thin secretions and supports airway clearance. Sodium is typically supplemented rather than restricted because children with cystic fibrosis lose excess salt in sweat, increasing risk for hyponatremic dehydration.

Question 39

A client with a history of alcohol abuse has been diagnosed with nutritional deficits. What is the best intervention for the nurse to implement?

Accepted Answer

Answer reason: Chronic alcohol use commonly leads to overall malnutrition and specific vitamin/protein deficits, so the priority is sustainable, comprehensive nutritional rehabilitation rather than a single macronutrient focus. Teaching and supporting a balanced diet addresses calories, protein, and micronutrients in a realistic long-term plan the client can continue after discharge. A high-calorie diet alone can still be nutrient-poor and does not correct common deficiencies (e.g., thiamine, folate). Routine daily calorie monitoring is less useful early on and may reduce adherence compared with practical coaching and meal planning.

Question 40

The client who is Jewish is to receive a kosher meal. Which direction by the nurse to the NA is appropriate?

Accepted Answer

Answer reason:  Kosher dietary practices require that food and serving items remain free from contact with non-kosher items to prevent contamination. Keeping plastic utensils sealed helps maintain their kosher status and avoids accidental mixing with non-kosher utensils or surfaces. Facing Mecca is an Islamic practice, not a Jewish requirement, and eye contact is not a standard kosher-related restriction. Additionally, kosher law prohibits mixing meat and milk, so verifying that a meal contains both would be inappropriate.

Question 41

The nurse is caring for the newly hospitalized child whose parents practice the Hindu faith. Which dietary modification should the nurse anticipate based on their faith beliefs?

Accepted Answer

Answer reason: Many Hindu families follow a vegetarian diet (often avoiding beef and sometimes all meat) as part of religious and ethical beliefs, so the nurse should anticipate and accommodate vegetarian meal selections. Avoiding pork is more characteristic of Islamic and Jewish dietary laws, not Hinduism. Abstaining from meat on Fridays is commonly associated with some Christian traditions, and “hot/cold” food therapy reflects cultural health beliefs rather than a core Hindu dietary restriction.

Question 42

The nurse is writing a plan of care for a 20-year-old client who sustained a spinal cord injury and is frequently hospitalized for kidney stones. What is the most appropriate intervention for the nurse to include in the plan?

Accepted Answer

Answer reason: Spinal cord injury commonly leads to neurogenic bladder with urinary stasis and recurrent bacteriuria, which increases the risk for infection-related (struvite) stones. Promoting urine acidification and reducing bacterial adherence are practical nursing nutrition/hydration measures to help decrease recurrent urinary complications in this context. The option selected targets urinary tract health, whereas increasing dairy intake can increase calcium load and may worsen calcium-based stone risk in some clients. Diet advice like yogurt or general fruits/vegetables is less directly tied to preventing the infection-stasis pathway driving stones in many clients with neurogenic bladder.

Question 43

The nurse is caring for a 3-year-old child with acute lymphocytic leukemia and notes the child has a decreased appetite. What is the priority nursing intervention?

Accepted Answer

Answer reason: Young children with leukemia commonly have poor appetite from fatigue, nausea, altered taste, or mucositis, so nursing care prioritizes maximizing calorie intake in small, acceptable amounts. Allowing snacks on demand supports frequent, small feedings and respects the child’s preferences, which increases the likelihood of actual intake. Pressuring a child to finish meals can worsen aversion and reduce intake further, making it a less effective approach. A dietitian consult is helpful but is not the most immediate, nurse-initiated priority compared with offering preferred, tolerable foods now. Oral hygiene is important but does not directly address the immediate nutrition need when intake is already reduced.

Question 44

After a nurse teaches a client with diverticular disease about proper diet, he fills out his lunch menu. Which selection by the client demonstrates the need for further teaching?

Accepted Answer

Answer reason: This menu item contains sunflower seeds, which is a classic “avoid” item in many nursing diet instructions for diverticular disease. The other choices provide softer foods and/or higher-fiber items (fruit, whole grains) without obvious seeds or nuts. Selecting a seeded food suggests the client has not integrated the key dietary restriction taught.

Question 45

The nurse is teaching the client newly diagnosed with type 2 DM. Which information should the nurse emphasize in the session?

Accepted Answer

Answer reason: Lifestyle modification is first-line management for type 2 diabetes and includes regular physical activity to improve insulin sensitivity and lower blood glucose. Exercising after a meal helps blunt postprandial hyperglycemia and reduces the risk of exercise-induced hypoglycemia in patients using glucose-lowering therapy. A routine, attainable target like 30 minutes most days supports weight management and cardiovascular risk reduction, both central in type 2 diabetes care. In contrast, advising a fixed pre-exercise carbohydrate load is not universally indicated and should be individualized based on medications, intensity, and glucose monitoring results.

Question 46

The nurse includes a referral to a dietitian in the plan of care for the client following total laryngectomy. Which should be the nurse’s primary rationale for initiating a nutritional referral?

Accepted Answer

Answer reason: After total laryngectomy, airflow no longer passes through the nose, which markedly reduces olfaction and diminishes flavor perception, commonly leading to poor appetite and reduced oral intake. A dietitian can help optimize calorie/protein density, suggest flavor-enhancement strategies, and tailor meal plans to prevent unintended weight loss during recovery. Swallowing mechanics are not typically altered by a total laryngectomy in the same way they are after some pharyngeal surgeries, so that is not the primary nutrition-referral rationale. Aspiration risk is generally reduced because the airway is separated from the alimentary tract, making aspiration-prevention teaching a less central nutrition-focused concern.

Question 47

The nurse is planning care for the infant with tetralogy of Fallot. Which intervention should the nurse include to best promote adequate nutrition?

Accepted Answer

Answer reason: Concentrating calories via fortified breast milk supports weight gain and growth while limiting the volume and work of feeding. Scheduled, frequent feedings help maintain adequate caloric intake when endurance is limited. Prostaglandin E1 is used to maintain ductal patency in select ductal-dependent lesions and is not a routine nutritional strategy, and water between feeds can decrease caloric intake without improving nutrition.

Question 48

Before administering an enteral feeding to the 2-month-old infant, the nurse aspirates 5 mL of gastric contents. Which action should the nurse take next?

Accepted Answer

Answer reason: The key principle is to minimize fluid/electrolyte loss and maintain gastric acid/enzymes when checking residuals in infants receiving enteral nutrition. A 5 mL aspirate in a 2-month-old is not, by itself, an indication to hold a feeding; instead, returning it helps prevent metabolic alkalosis and unnecessary nutrient loss. Withholding the feeding is typically reserved for large or abnormal residuals and/or signs of intolerance (e.g., emesis, abdominal distention, respiratory compromise). Discarding the aspirate or “replacing” it with saline is not appropriate because it alters the infant’s fluid and electrolyte balance and removes gastric contents that should be preserved.

Question 49

The child hospitalized following surgical intervention for osteosarcoma is not interested in eating. Which nursing intervention would best support the child’s nutrition?

Accepted Answer

Answer reason: Postoperative and oncology-related decreased appetite is best managed by offering small, frequent, calorie-containing and fluid-containing items to prevent dehydration and reduce catabolism when full meals are poorly tolerated. This approach increases overall intake by matching limited appetite and nausea/fatigue with manageable portions and choices. It also supports comfort because cool liquids and soft foods can be easier to tolerate and may soothe oral discomfort, which is common in cancer care. Relying on preferred foods alone or distraction may not provide adequate nutrient/fluid volume, and family presence can help emotionally but is less directly effective than frequent nutrient-dense offerings.

Question 50

The nurse teaches the client with iron-deficiency anemia to eat foods high in iron and foods that contain vitamin C at the same meal to increase iron absorption. The nurse evaluates that teaching is effective when the client selects the meal that includes which foods?

Accepted Answer

Answer reason: A meal pairing a clearly iron-rich food with a vitamin C source best demonstrates the teaching goal. Red meat provides highly bioavailable heme iron, and broccoli contributes vitamin C, supporting improved absorption. In contrast, dairy foods can inhibit iron absorption due to calcium competing with iron for uptake.

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