ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 60 Questions
Question 1 of 5
A client is in the family practice clinic. Today the client weighs 180.4 pounds (84.7 kg). Six months ago, the client weighed 201.8 pounds (96.2 kg). What action by the nurse is best?
Correct Answer: A
Rationale: This client has had 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on the risk factors, a blood glucose test may be warranted.
Question 2 of 5
A nursing student is studying nutritional problems and learns that kwashiorer is distinguished from measures and which finding?
Correct Answer: C
Rationale: Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition.
Question 3 of 5
A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessment is a priority?
Correct Answer: B
Rationale: A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and protein levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.
Question 4 of 5
A client is receiving bolus feedings through a Dobbloff tube. What action by the nurse is most important?
Correct Answer: B
Rationale: For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will not prevent misplacement issues. Weighing the client is important to determine if nutritional goals are being met.
Question 5 of 5
A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?
Correct Answer: C
Rationale: The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate without a provider's order. Checking gastric residual is important but not while the client is vomiting. Continuing to feed the client during vomiting is unsafe.