Question

A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Answer 1

Correct Answers:

Remove the bedpan from the client's sight.
Provide mouth care before feeding.
Assess for pain prior to mealtime.

Rationale :

🟢 Remove the bedpan from the client’s sight

🔸The environment plays a key role in appetite stimulation..

🔸Seeing a bedpan while trying to eat can cause nausea, reduced appetite, and food aversion.

🔸Removing it and ensuring a pleasant, odor-free, clean environment supports better food intake.

🔸This intervention is especially important in long-term care, where clients may already have diminished appetite due to chronic illness, medication side effects, or age-related changes.

🟢 Provide mouth care before feeding

🔸Poor oral hygiene (dry mouth, coated tongue, bad taste, or ill-fitting dentures) can decrease a client’s desire to eat.

🔸Performing mouth care before meals improves taste sensation, comfort, and swallowing ability, directly enhancing nutritional intake.

🔸In long-term care, many clients suffer from xerostomia (dry mouth) due to medications; mouth care helps mitigate this barrier.

🔸This action also reduces the risk of oral infections that could further impair eating.

🟢 Assess for pain prior to mealtime

🔸Pain can suppress appetite and make eating uncomfortable, leading to poor nutritional intake.

🔸By assessing and managing pain before meals, the nurse ensures the client can focus on eating rather than discomfort.

🔸For example, clients with arthritis, dental pain, or post-surgical discomfort may eat better after appropriate analgesic administration.

🔸Addressing pain contributes to both adequate nutrition and overall quality of life.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Wrap gloved fingers with gauze to remove dentures

Rationale :

✅ Safe removal: Wrapping gloved fingers with gauze improves grip and control when removing dentures, reducing the risk of dropping or damaging them.

✅ Infection control: Wearing gloves prevents transmission of microorganisms between the nurse, caregiver, and client, maintaining proper hygiene.

✅ Comfort for the client: Gauze provides a soft grip that reduces discomfort to the client’s gums and oral tissues during denture removal.

✅ Prevention of injury: Proper technique avoids scraping or traumatizing the mucosa, which is especially important in older adults with fragile oral tissues.

✅ First step in denture care: Safe removal is essential before cleaning with a denture brush, rinsing, and storing dentures in a container with water or denture solution, not a dry container.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Include supplemental pancreatic enzymes with snacks."

Rationale :

🫁Cystic fibrosis leads to pancreatic enzyme deficiency, causing malabsorption of fat and nutrients. To prevent malnutrition, pancreatic enzyme replacement therapy (PERT) must be taken with every meal and every snack.

🫁Skipping enzymes with snacks results in fat and protein malabsorption, contributing to weight loss, steatorrhea, and fatigue.

🫁Enzymes work by replacing the missing pancreatic secretions, allowing the body to digest and absorb essential nutrients, fats, and fat-soluble vitamins (A, D, E, K).

🫁Teaching emphasizes that enzymes should be taken immediately before eating and in adequate amounts, with adjustments made under medical guidance based on stool quality and nutritional status.

🫁Adequate enzyme supplementation improves growth, energy levels, and overall nutritional outcomes in adolescents with cystic fibrosis.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Provide a vitamin C supplement.

Rationale :

🌐Vitamin C is essential for collagen synthesis and wound healing, which are critical in burn recovery where large areas of tissue must regenerate.

🌐Clients with moderate partial-thickness burns over 30% TBSA have increased metabolic and nutritional demands, requiring supplements to promote tissue repair and prevent complications.

🌐Vitamin C also enhances immune function and capillary strength, helping to reduce infection risk and improve overall healing outcomes.

🌐Burn patients need a high-protein, high-calorie diet plus vitamin and mineral supplements, including vitamin A, vitamin C, and zinc, rather than restriction of these nutrients.

🌐Supplementing vitamin C supports faster recovery, stronger scar tissue, and reduced healing complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Muscle weakness

Rationale :

💠 Hypokalemia affects skeletal muscle function, leading to weakness that may progress from mild fatigue to severe paralysis in extreme cases.

💠 Potassium is critical for nerve impulse conduction and muscle contraction; a deficit disrupts these processes, resulting in decreased strength and sluggish reflexes.

💠 Other clinical signs of hypokalemia can include leg cramps, shallow respirations, weak pulse, and cardiac dysrhythmias.

💠 Findings like Chvostek’s sign are linked to hypocalcemia, not potassium imbalance, while seizures are more associated with sodium imbalances.

💠 Monitoring muscle strength, cardiac rhythm, and potassium levels is essential to prevent complications such as respiratory compromise or arrhythmias.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

1 cup brown rice

Rationale :

🥭Dried apricots are extremely rich in potassium, providing over 1,500 mg per cup, making them one of the highest potassium-containing foods.

🥭Potassium is crucial for nerve conduction, muscle contraction, and cardiac rhythm regulation, and deficiency can lead to weakness, arrhythmias, and cramping.

🥭Cooked quinoa and brown rice contain potassium but in significantly lower amounts (about 300–320 mg per cup).

🥭Cheddar cheese is high in calcium and protein but has relatively little potassium compared to dried fruits.

🥭Teaching clients to select dried fruits, bananas, spinach, sweet potatoes, and avocados is essential when increasing dietary potassium intake.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

1400

Rationale :

154 lb ÷ 2.2 = 70 kg

70 × 30 = 2100 cal/day

70 × 10 = 700 cal/day reduction

2100 – 700 = 1400 cal/day ✅

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Instruct the client to tuck their chin to their chest before swallowing.

Rationale :

🍃 Chin-tuck maneuver helps close the airway, directing food and liquid toward the esophagus and reducing the risk of aspiration.

🍃 Dysphagia increases aspiration risk, which can lead to pneumonia and respiratory complications; safe swallowing techniques are essential.

🍃 The chin-to-chest position improves swallowing coordination, especially for clients with neuromuscular or structural swallowing impairments.

🍃 This intervention is part of aspiration precautions, which also include upright positioning, slow feeding, and thickened liquids as prescribed.

🍃 Educating both the client and caregiver ensures consistent and safe feeding practices.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

The force of the client's urinary stream has improved.

Rationale :

💧 BPH causes urinary obstruction, leading to weak stream, hesitancy, and incomplete bladder emptying.

💧 Improved force of urinary stream directly shows that treatment has relieved obstruction and restored better urine flow.

💧 This improvement also reduces complications such as urinary retention, infections, and bladder distension.

💧 Other findings like normal creatinine or stool passage do not measure effectiveness of BPH therapy.

💧 The primary goal of treatment is improved voiding ability, confirmed by stronger stream and reduced urinary symptoms.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Increased hematocrit

Rationale :

💧 Clostridium difficile infection causes profuse watery diarrhea, leading to dehydration and fluid volume deficit.

💧 In fluid volume deficit, the hematocrit level rises because there is less plasma volume, making the concentration of red blood cells appear higher.

💧 Other signs of fluid deficit include tachycardia, hypotension, dry mucous membranes, and poor skin turgor.

💧 Decreased urine specific gravity and clear urine indicate dilute urine, which is more consistent with fluid excess.

💧 Recognizing increased hematocrit as a marker helps guide fluid replacement and prevent hypovolemic complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

2 :
A nurse is teaching about denture care to the partner of a client who is unable to perform oral hygiene. Which of the following should the nurse include in the teaching?

3 :
A nurse is providing teaching to an adolescent client who has cystic fibrosis and reports increased fatigue and weight loss. Which of the following instructions should the nurse include in the teaching?

4 :
A nurse is caring for a client who has moderate partial-thickness burns over 30% of their total body surface area. Which of the following actions should the nurse take?

5 :
A nurse is assessing a client who has a decreased potassium level. Which of the following findings should the nurse expect?

6 :
A nurse is teaching a client about foods that are high in potassium. The nurse should identify that which of the following foods contains the highest amount of potassium?

8 :
A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take to reduce the risk for aspiration?

9 :
A nurse is caring for a client who has benign prostatic hyperplasia. Which of the following findings indicates that the client's treatment has been effective?

10 :
A nurse is reviewing the laboratory findings of a client who has Clostridium difficile. Which of the following findings should indicate to the nurse that the client is experiencing a fluid volume deficit?

QLexNursing

1 : A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

2 : A nurse is teaching about denture care to the partner of a client who is unable to perform oral hygiene. Which of the following should the nurse include in the teaching?

3 : A nurse is providing teaching to an adolescent client who has cystic fibrosis and reports increased fatigue and weight loss. Which of the following instructions should the nurse include in the teaching?

4 : A nurse is caring for a client who has moderate partial-thickness burns over 30% of their total body surface area. Which of the following actions should the nurse take?

5 : A nurse is assessing a client who has a decreased potassium level. Which of the following findings should the nurse expect?

6 : A nurse is teaching a client about foods that are high in potassium. The nurse should identify that which of the following foods contains the highest amount of potassium?

8 : A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take to reduce the risk for aspiration?

9 : A nurse is caring for a client who has benign prostatic hyperplasia. Which of the following findings indicates that the client's treatment has been effective?

10 : A nurse is reviewing the laboratory findings of a client who has Clostridium difficile. Which of the following findings should indicate to the nurse that the client is experiencing a fluid volume deficit?

1 :
A nurse in a long-term care facility is implementing a nutrition plan for a client who is at risk for malnutrition. Which of the following actions should the nurse include in the plan? (Select all that apply.)

2 :
A nurse is teaching about denture care to the partner of a client who is unable to perform oral hygiene. Which of the following should the nurse include in the teaching?

3 :
A nurse is providing teaching to an adolescent client who has cystic fibrosis and reports increased fatigue and weight loss. Which of the following instructions should the nurse include in the teaching?

4 :
A nurse is caring for a client who has moderate partial-thickness burns over 30% of their total body surface area. Which of the following actions should the nurse take?

5 :
A nurse is assessing a client who has a decreased potassium level. Which of the following findings should the nurse expect?

6 :
A nurse is teaching a client about foods that are high in potassium. The nurse should identify that which of the following foods contains the highest amount of potassium?

8 :
A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take to reduce the risk for aspiration?

9 :
A nurse is caring for a client who has benign prostatic hyperplasia. Which of the following findings indicates that the client's treatment has been effective?

10 :
A nurse is reviewing the laboratory findings of a client who has Clostridium difficile. Which of the following findings should indicate to the nurse that the client is experiencing a fluid volume deficit?