Question

A nurse on a medical-surgical unit is caring for a client.

Answer 1

Correct Answers:

Fluid overload
Hyperglycemia
Refeeding syndrome

Rationale :

Fluid Overload

🎀 Rapid weight gain of 2 kg (80 → 82 kg) in 24 hours reflects acute fluid retention, not nutritional gain.

🎀 Bilateral crackles at the lung bases indicate pulmonary fluid accumulation.

🎀 +3 bilateral lower-extremity edema demonstrates significant third-spacing of fluid.

🎀 Dyspnea and increased respiratory rate (24/min) are classic signs of pulmonary congestion.

🎀 Positive fluid balance (2,600 mL intake vs 1,000 mL output) confirms excess intravascular volume, commonly seen with TPN.

Hyperglycemia

🎀 Blood glucose of 210 mg/dL is clearly elevated and is a known complication of TPN, which contains high dextrose concentrations.

🎀 Continuous TPN infusion promotes sustained glucose delivery, increasing the risk of hyperglycemia.

🎀 Physiologic stress of illness increases insulin resistance, worsening glucose control.

🎀 Absence of prior diabetes supports TPN as the primary cause of hyperglycemia.

🎀 Uncontrolled glucose levels increase the risk of infection, dehydration, and osmotic diuresis.

Refeeding Syndrome

🎀 Hypophosphatemia (2.6 mg/dL) is a hallmark laboratory finding of refeeding syndrome.

🎀 Hypokalemia (3.1 mEq/L) results from insulin-driven intracellular electrolyte shifts after refeeding.

🎀 Low magnesium (1.0 mEq/L) further supports the diagnosis.

🎀 Prolonged NPO status followed by initiation of TPN places the client at high risk.

🎀 Fluid retention and edema occur due to sodium and water shifts associated with refeeding.

Infection

🎀 White blood cell count remains normal (8,500/mm³), which does not support infection.

🎀 No fever, chills, or PICC-line site abnormalities are documented.

🎀 Anemia — Incorrect Rationale

🎀 Hemoglobin (13 g/dL) and hematocrit (38%) are within normal limits.

🎀 There are no signs of bleeding, hypoxia, or reduced oxygen-carrying capacity.

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Answer 2

Correct Answers:

Eat small frequent meals.
Avoid beverages containing caffeine.
Consume a high-protein diet.
Drink fluids containing potassium.

Rationale :

Eat Small Frequent Meals

🎀 Eating small frequent meals reduces intestinal workload and minimizes bowel stimulation during Crohn’s disease remission.

🎀 Smaller meals help prevent postprandial cramping and diarrhea.

🎀 This approach improves nutrient absorption in an inflamed gastrointestinal tract.

🎀 It helps maintain energy levels in clients with recent weight loss.

🎀 Frequent meals are better tolerated during intestinal healing.

Avoid Beverages Containing Caffeine

🎀 Caffeine stimulates intestinal motility, which can worsen diarrhea.

🎀 It increases gastric acid secretion, aggravating abdominal discomfort.

🎀 Avoiding caffeine helps reduce bowel irritation.

🎀 Caffeine can contribute to dehydration, worsening fluid imbalance.

🎀 Limiting caffeine supports symptom control during recovery.

Consume a High-Protein Diet

🎀 High-protein intake supports tissue repair of the intestinal mucosa.

🎀 Protein helps restore lean body mass lost from chronic inflammation.

🎀 It promotes immune function, important in inflammatory bowel disease.

🎀 Adequate protein prevents muscle wasting associated with weight loss.

🎀 Protein supports overall nutritional rehabilitation.

Drink Fluids Containing Potassium

🎀 Chronic diarrhea leads to potassium loss, increasing risk of hypokalemia.

🎀 Potassium replacement supports cardiac and neuromuscular function.

🎀 Electrolyte-rich fluids prevent dehydration.

🎀 Maintaining potassium balance reduces fatigue and weakness.

🎀 Proper hydration improves gastrointestinal recovery.

Consume a Low-Calorie Diet

🎀 A low-calorie diet worsens weight loss and malnutrition.

🎀 Clients with Crohn’s disease require increased caloric intake, not restriction.

Choose Foods That Are High in Fiber

🎀 High-fiber foods can increase bowel irritation and diarrhea.

🎀 Fiber may worsen symptoms during active or recent flare-ups.

Consume Raw Vegetables With Skin

🎀 Raw vegetables and skins are difficult to digest and irritate the bowel.

🎀 These foods increase the risk of abdominal pain and diarrhea.

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Answer 3

Correct Answers

Blank 1 Correct Option: ability to purchase food
Blank 2 Correct Option: blood pressure

Rationale :

Ability to Purchase Food

🎀 The client reports difficulty purchasing food, which directly threatens basic nutritional needs.

🎀 A BMI of 18.5 with decreased appetite indicates undernutrition risk.

🎀 Reliance on frozen meals and canned soups suggests poor dietary quality.

🎀 Inability to access food compromises healing, immunity, and medication effectiveness.

🎀 According to Maslow’s hierarchy, physiologic needs must be addressed before other concerns.

Blood Pressure

🎀 A blood pressure of 146/90 mm Hg reflects uncontrolled hypertension.

🎀 Elevated blood pressure increases the risk for stroke, heart disease, and kidney damage.

🎀 Hypertension requires early intervention to prevent long-term complications.

🎀 Addressing nutrition first supports better blood pressure management.

🎀 Blood pressure control follows once immediate survival needs are stabilized.

Hemoglobin

🎀 The hemoglobin level of 11 g/dL indicates mild anemia, not an immediate threat.

🎀 This condition can be addressed after nutritional access is secured.

Blood Glucose

🎀 Casual glucose levels below 200 mg/dL are elevated but not emergent.

🎀 Nutritional stability is required before effective glucose management.

Housing

🎀 The client’s home environment is safe, with no immediate hazards noted.

🎀 Housing does not pose an urgent risk compared with food insecurity

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Answer 4

Correct Answers:

Drink liquids first at mealtime.
Rest after meals with head elevated
Drink 1 cup of liquid after each bowel movement.
Drink ginger tea
Eat foods at warm temperatures
Limit caffeine intake
Eat yogurt with active cultures.
Avoid gas-forming foods.

Rationale :

Drink Liquids First at Mealtime

🎀 Severe diarrhea and vomiting place the client at high risk for dehydration.

🎀 Drinking liquids first prioritizes fluid replacement over solid intake.

🎀 Fluids are better tolerated when nausea is present.

🎀 Adequate hydration supports circulatory volume and kidney function.

🎀 Early fluid intake helps prevent electrolyte imbalance.

Rest After Meals With Head Elevated

🎀 Fatigue and weakness indicate the need for energy conservation.

🎀 Head elevation reduces the risk of nausea and vomiting.

🎀 Upright positioning decreases gastric reflux.

🎀 Rest improves digestive tolerance during illness.

🎀 This positioning supports comfort and recovery.

Drink 1 Cup of Liquid After Each Bowel Movement

🎀 Each episode of diarrhea causes fluid loss.

🎀 Replacing fluids helps prevent hypovolemia.

🎀 This practice reduces the risk of decreased urine output.

🎀 Fluid replacement supports blood pressure stability.

🎀 It promotes overall hydration balance.

Drink Ginger Tea

🎀 Ginger has antiemetic properties that reduce nausea.

🎀 It improves gastric emptying.

🎀 Ginger is well tolerated when oral intake is limited.

🎀 It decreases abdominal cramping.

🎀 Ginger supports symptom relief without medication side effects.

Eat Foods at Warm Temperatures

🎀 Warm foods are easier to digest than very hot or cold foods.

🎀 Extreme temperatures can worsen gastric irritation.

🎀 Warm foods reduce intestinal spasms.

🎀 They are better tolerated during active GI illness.

🎀 This promotes nutritional intake without worsening symptoms.

Limit Caffeine Intake

🎀 Caffeine increases intestinal motility, worsening diarrhea.

🎀 It contributes to fluid loss through diuresis.

🎀 Caffeine increases gastric acid secretion.

🎀 Limiting caffeine reduces GI irritation.

🎀 Avoidance supports hydration and symptom control.

Eat Yogurt With Active Cultures

🎀 Probiotics help restore normal gut flora.

🎀 Diarrhea disrupts intestinal microbiota balance.

🎀 Active cultures support immune function.

🎀 Yogurt improves stool consistency.

🎀 This supports faster gastrointestinal recovery.

Avoid Gas-Forming Foods

🎀 Gas-forming foods increase abdominal distention.

🎀 Distention worsens cramping and discomfort.

🎀 Avoidance reduces bowel irritation.

🎀 This improves tolerance of oral intake.

🎀 Symptom control supports healing and hydration.

Increase Intake of Foods With High-Fiber Content

🎀 High fiber increases stool bulk, worsening diarrhea.

🎀 Fiber stimulates intestinal motility, aggravating symptoms.

Increase Intake of Foods With High-Fat Content

🎀 High-fat foods delay gastric emptying.

🎀 Fat worsens nausea and abdominal cramping.

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Answer 5

Correct Answers:

Use a washcloth to clean the denture surfaces.
Wrap gloved fingers with gauze to remove dentures.

Rationale :

🎀 A washcloth provides gentle friction that effectively removes food particles and plaque.

🎀 It reduces the risk of scratching denture material compared with hard brushes.

🎀 Washcloths are easier to control for caregivers performing assisted oral hygiene.

🎀 Gentle cleaning helps prevent mucosal irritation.

🎀 Proper denture cleaning supports oral comfort and infection prevention.

Wrap Gloved Fingers With Gauze to Remove Dentures

🎀 Gauze improves grip, making denture removal safer and easier.

🎀 Gloves and gauze reduce the risk of slipping and dropping dentures.

🎀 This method minimizes trauma to the oral mucosa.

🎀 It promotes infection control during oral care.

🎀 This is the recommended technique for dependent clients.

Floss Dentures as Part of Daily Cleaning

🎀 Dentures do not have contact points like natural teeth that require flossing.

🎀 Flossing can damage denture structure.

Wipe Dentures Before Storing Them in a Dry Container at Night

🎀 Dentures must be stored in water or denture solution to prevent warping.

🎀 Dry storage increases the risk of cracks and poor fit.

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Answer 6

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 presence of a bedpan can decrease appetite and cause nausea.

🎀 Removing unpleasant stimuli promotes a more comfortable eating environment.

🎀 A clean environment supports psychological readiness to eat.

🎀 This action reduces sensory triggers that suppress hunger.

🎀 Improving the dining atmosphere helps increase oral intake.

Provide Mouth Care Before Feeding

🎀 Oral hygiene improves taste sensation.

🎀 Mouth care removes debris and bacteria that interfere with appetite.

🎀 Clean oral mucosa enhances comfort while eating.

🎀 This intervention helps prevent oral infections that reduce intake.

🎀 Improved mouth comfort supports adequate nutrition.

Assess for Pain Prior to Mealtime

🎀 Pain reduces appetite and willingness to eat.

🎀 Identifying pain allows for timely pain management before meals.

🎀 Uncontrolled pain increases stress and anorexia.

🎀 Pain relief improves meal tolerance.

🎀 Addressing pain supports nutritional adequacy.

Discourage Snacks Between Meals

🎀 Clients at risk for malnutrition benefit from frequent small meals and snacks.

🎀 Discouraging snacks reduces total caloric intake.

Administer Antiemetics Following the Meal

🎀 Antiemetics are most effective when given before eating, not after.

🎀 Post-meal administration does not prevent nausea-related intake reduction.

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Answer 7

Correct Answers:

The client uses a plate with a guard.

Rationale :

🎀 A plate guard prevents food from sliding off the plate, making self-feeding easier.

🎀 This equipment supports limited joint mobility commonly seen in rheumatoid arthritis.

🎀 Plate guards reduce the need for fine motor control of the hands and fingers.

🎀 Using a guard helps conserve energy and decreases meal-time frustration.

🎀 This adaptive device promotes independence and adequate nutritional intake.

Small-Handled Spoon

🎀 Small handles increase the need for finger flexion and grip strength.

🎀 Clients with rheumatoid arthritis benefit from large-handled utensils, not small ones.

Glass for Liquids

🎀 A regular glass does not provide grip stability or spill protection.

🎀 Adaptive cups with lids or two handles are preferred.

Plastic Disposable Fork

🎀 Disposable utensils lack weight and stability, making them harder to control.

🎀 Adaptive forks are typically weighted or built-up, not disposable.

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Answer 8

Correct Answers:

"The TPN will be administered through a central venous catheter."

Rationale :

🎀 TPN solutions are highly hypertonic, requiring infusion into a large central vein.

🎀 A central venous catheter allows rapid dilution of the solution, preventing vein damage.

🎀 Peripheral veins cannot tolerate the high dextrose concentration of TPN.

🎀 Central administration reduces the risk of phlebitis and infiltration.

🎀 This method ensures safe and effective delivery of complete nutrition.

Higher Levels of Vitamins Than Recommended Daily Intake

🎀 TPN provides vitamins at recommended levels, not excessive amounts.

🎀 Excess vitamin supplementation increases the risk of toxicity, especially in kidney disease.

Higher in Fats and Protein, Lower in Carbohydrates

🎀 TPN contains balanced macronutrients, including carbohydrates as the primary energy source.

🎀 Carbohydrates are essential to prevent protein breakdown for energy.

Needed Because You Are Burning Excessive Calories

🎀 TPN is prescribed due to inability to use the gastrointestinal tract, not excess calorie burning.

🎀 The indication is nutritional support, not increased metabolic demand.

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Answer 9

Correct Answers:

Calcium

Rationale :

🎀 Calcium is essential for transmission of nerve impulses at the neuromuscular junction.

🎀 It allows neurotransmitter release from nerve endings.

🎀 Calcium plays a key role in muscle contraction, which depends on nerve signaling.

🎀 Low calcium levels can cause tetany, numbness, and tingling, indicating impaired nerve function.

🎀 Adequate calcium maintains normal neuromuscular excitability.

Phosphorus

🎀 Phosphorus is primarily involved in bone formation and energy metabolism.

🎀 It does not directly control nerve impulse transmission.

Zinc

🎀 Zinc supports immune function and wound healing.

🎀 It is not responsible for electrical nerve signaling.

Chloride

🎀 Chloride helps maintain acid–base and fluid balance.

🎀 It does not play a primary role in synaptic nerve transmission.

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Answer 10

Correct Answers:

Check for gastric residual

Rationale :

🎀 Nausea and abdominal distention are classic signs of delayed gastric emptying.

🎀 Checking gastric residual volume assesses the client’s tolerance of enteral feeding.

🎀 Elevated residuals increase the risk of aspiration.

🎀 Early identification allows timely adjustment of feeding rate or formula.

🎀 This action promotes patient safety and gastrointestinal comfort.

Increase the Rate of the Feeding

🎀 Increasing the rate worsens gastric distention and nausea.

🎀 Faster infusion increases the risk of aspiration and intolerance.

Add Water to the Feeding

🎀 Adding water does not address delayed gastric emptying.

🎀 Excess fluid may worsen abdominal distention.

Request a Higher-Fat Formula

🎀 High-fat formulas slow gastric emptying.

🎀 This can increase nausea, bloating, and feeding intolerance.

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QLexNursing

1 :
A nurse on a medical-surgical unit is caring for a client.

Answer Options

2 :
A nurse is caring for a client on a medical-surgical unit.

Answer Options

3 :
A home health nurse is caring for a client.

Correct Answers

4 :
A nurse is caring for a client in an urgent care facility.

Answer Options

5 :
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?

6 :
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.)

7 :
A nurse is caring for a client who has rheumatoid arthritis and uses adaptive meal equipment. Which of the following actions by the client indicates correct use of the equipment?

8 :
A nurse is caring for a client who has acute kidney injury and has been prescribed total parenteral nutrition (TPN). When educating the client on the use of TPN, which of the following information should the nurse include?

9 :
A nurse is preparing to teach a group of clients about vitamins and minerals. The nurse should include in the teaching that which of the following minerals is necessary for the transmission of nerve impulses?

10 :
A nurse is caring for a client who is receiving continuous enteral tube feeding and reports nausea and abdominal distention. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse on a medical-surgical unit is caring for a client.

Answer Options

2 : A nurse is caring for a client on a medical-surgical unit.

Answer Options

3 : A home health nurse is caring for a client.

Correct Answers

4 : A nurse is caring for a client in an urgent care facility.

Answer Options

5 : 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?

6 : 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.)

7 : A nurse is caring for a client who has rheumatoid arthritis and uses adaptive meal equipment. Which of the following actions by the client indicates correct use of the equipment?

8 : A nurse is caring for a client who has acute kidney injury and has been prescribed total parenteral nutrition (TPN). When educating the client on the use of TPN, which of the following information should the nurse include?

9 : A nurse is preparing to teach a group of clients about vitamins and minerals. The nurse should include in the teaching that which of the following minerals is necessary for the transmission of nerve impulses?

10 : A nurse is caring for a client who is receiving continuous enteral tube feeding and reports nausea and abdominal distention. Which of the following actions should the nurse take?

1 :
A nurse on a medical-surgical unit is caring for a client.

2 :
A nurse is caring for a client on a medical-surgical unit.

3 :
A home health nurse is caring for a client.

4 :
A nurse is caring for a client in an urgent care facility.

5 :
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?

6 :
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.)

7 :
A nurse is caring for a client who has rheumatoid arthritis and uses adaptive meal equipment. Which of the following actions by the client indicates correct use of the equipment?

8 :
A nurse is caring for a client who has acute kidney injury and has been prescribed total parenteral nutrition (TPN). When educating the client on the use of TPN, which of the following information should the nurse include?

9 :
A nurse is preparing to teach a group of clients about vitamins and minerals. The nurse should include in the teaching that which of the following minerals is necessary for the transmission of nerve impulses?

10 :
A nurse is caring for a client who is receiving continuous enteral tube feeding and reports nausea and abdominal distention. Which of the following actions should the nurse take?