Question

A student nurse is assessing a patient's food choices as part of a nutritional assessment. Which of the following actions is MOST appropriate to identify potential dietary risk factors?

Answer 1

Correct Answers:

Ask the patient to recall their food intake over the past 24 hours.

Rationale :

🍎 A 24-hour dietary recall is the most accurate first-line nutrition assessment tool because it captures real dietary patterns, portion sizes, and nutrient sources.

🍎 It helps identify risk factors such as under-eating, overeating, or nutrient deficiencies by reviewing actual intake.

🍎 It incorporates cultural and personal food choices, which are essential in nutritional planning.

🍎 It gives a complete picture of the patient’s eating behaviors, unlike observations that show only one moment.

🍎 It forms the basis for individualized dietary recommendations, following proper nursing assessment steps.

Why the Incorrect Answers Are Wrong

❌ Observe the patient during meal times

🚫 Only captures one meal, not overall nutrition.

🚫 Does not reflect what a patient eats before admission or between meals.

🚫 Not reliable as the primary assessment method.

❌ Check BMI

🚫 BMI shows body size, not dietary habits.

🚫 Does not identify nutrient deficiencies or excesses.

🚫 Cannot replace a full nutritional assessment.

❌ Recommend a low-sodium diet without assessment

🚫 Interventions must not occur before assessing the patient.

🚫 May be inappropriate or unsafe depending on conditions.

🚫 Violates the nursing process.

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Answer 2

Correct Answers:

The patient should inhale slowly and deeply through the mouthpiece to reach the target volume.

Rationale :

🌬️ Incentive spirometers measure inhalation, not exhalation.

🌬️ Deep inhalation reopens collapsed alveoli, preventing atelectasis after surgery.

🌬️ Slow inhalation promotes optimal lung expansion, improving oxygenation.

🌬️ The rising indicator gives visual feedback, helping the patient meet the target volume.

🌬️ This technique is essential for preventing postoperative complications such as pneumonia.

Why the Incorrect Answers Are Wrong

❌ Exhale forcefully into the spirometer

🚫 Incentive spirometers are not used for exhalation, only inhalation.

🚫 Exhaling forcefully could damage the device or give false readings.

❌ Use the spirometer once a day

🚫 Effectiveness requires multiple uses per hour, not once daily.

🚫 Would not prevent atelectasis.

❌ Hold breath after exhaling

🚫 Breath-holding must occur after inhaling, not after exhaling.

🚫 Incorrect technique reduces lung expansion.

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Answer 3

Correct Answers:

Open sores or ulcerations around the nostrils.

Rationale :

🩹 Ulcerations indicate severe skin breakdown, requiring immediate intervention.

🩹 Breaks in the skin can lead to infection and worsening tissue damage.

🩹 Indicates that oxygen tubing is causing harmful pressure or friction.

🩹 May require adjusting the device or switching oxygen delivery method.

🩹 This finding is urgent, not routine.

Why the Incorrect Answers Are Wrong

❌ Redness and irritation on the nares

🚫 Early irritation is expected with nasal cannulas.

🚫 Not an emergency unless it progresses.

❌ Mild dryness of the nasal mucosa

🚫 Dryness is normal with oxygen use.

🚫 Can be relieved with humidification.

❌ Indentation marks on the cheeks

🚫 Temporary pressure marks occur with tubing.

🚫 Not a sign of tissue damage.

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Answer 4

Correct Answers:

20

Rationale :

🔢 Supply: 125 mg per 5 mL = 25 mg/mL.

🔢 Ordered dose: 500 mg per dose.

🔢 Calculation: 500 mg ÷ 25 mg/mL = 20 mL.

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Answer 5

Correct Answers:

The stoma has a bluish discoloration.

Rationale :

🩸 A bluish or purple stoma indicates ischemia, meaning reduced blood flow.

🩸 This is a medical emergency—necrosis may occur if not treated quickly.

🩸 A healthy stoma should be pink or red and moist.

🩸 Immediate provider notification is required to restore perfusion.

🩸 Early recognition prevents tissue death and infection.

Why the Incorrect Answers Are Wrong

❌ Pink and moist stoma

🚫 This is the normal expected finding, not a complication.

❌ Skin slightly red around stoma

🚫 Mild peristomal redness is common from appliance friction.

🚫 Not a sign of stoma compromise.

❌ Passing gas through colostomy

🚫 Indicates healthy bowel function and return of activity.

🚫 Not a complication at all.

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Answer 6

Correct Answers:

Social Worker
Pharmacist
Dietitian

Rationale :

✔ Social Worker

🧩 Social workers play an essential role in coordinating community and social support services for patients with diabetes and chronic wounds, especially when long-term care or rehabilitation is required.

🧩 They help the patient access home health services, transportation, insurance resources, or financial support programs, which can significantly affect the patient’s ability to adhere to wound care instructions.

🧩 Social workers assist with discharge planning, ensuring continuity of care once the patient leaves the hospital.

🧩 They address psychosocial barriers—such as depression, stress, or lack of family support—that can negatively impact wound healing and diabetes management.

🧩 Their involvement helps promote a holistic plan of care that considers the patient’s social, emotional, and environmental needs.

✔ Pharmacist

💊 Pharmacists ensure medication safety, especially important for diabetic patients who may be taking insulin, oral hypoglycemics, antibiotics, and analgesics.

💊 They assess for drug interactions, appropriate dosing, and potential side effects, which is vital when managing infection and promoting wound healing.

💊 Pharmacists educate the patient on proper insulin use, timing, and storage, as well as how medications impact blood glucose levels.

💊 They provide guidance on antibiotic therapy, ensuring the patient receives the correct drug and duration for wound infections.

💊 Their expertise helps prevent medication errors and optimize therapeutic outcomes, directly affecting wound healing and glucose control.

✔ Dietitian

🥗 Dietitians play a central role in managing diabetes and supporting wound healing, as nutrition directly influences blood glucose control and tissue repair.

🥗 They assess the patient’s dietary patterns and create an individualized meal plan that supports stable blood sugar levels and provides adequate protein, vitamins, and minerals for wound healing.

🥗 Dietitians educate the patient about carbohydrate counting, portion control, and balanced meals, which are essential for long-term diabetes management.

🥗 They ensure the patient’s diet includes nutrients like protein, zinc, and vitamin C, which promote stronger and faster wound healing.

🥗 Their involvement helps reduce complications and supports the patient in maintaining a sustainable, healthy lifestyle after discharge.

❌ Incorrect Options (Not part of the wound-care healthcare team)

Electrician — 🚫 Not involved in patient health or wound management.

Police Officer — 🚫 No clinical or therapeutic role in diabetic wound care.

Lawyer — 🚫 Not related to healthcare planning or wound treatment.

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Answer 7

Correct Answers:

Male

Rationale :

👨‍⚕️ “Andr” is a medical and scientific root meaning male or man.

👨‍⚕️ It appears in terms like androgen (male hormone) and andrology (study of male reproductive health).

👨‍⚕️ The prefix specifically relates to male characteristics, sex hormones, or male reproductive function.

👨‍⚕️ It is commonly used in medical terminology, endocrinology, and anatomy.

👨‍⚕️ Recognizing this root helps decode complex medical words involving male physiology.

Why the Incorrect Answers Are Wrong

❌ Poison — ☠️ Root for poison is tox/o or tox/ic.

❌ Night — 🌙 Root for night is nyct/o.

❌ Bladder — 🫙 Root for bladder is cyst/o.

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Answer 8

Correct Answers:

The patient's risk of developing skin irritation or breakdown.

Rationale :

🩹 Skin integrity is the #1 safety consideration with external catheters, especially in males, because poor adherence or moisture can lead to breakdown.

🩹 External catheters can trap moisture, cause friction, or lead to dermatitis if not properly applied.

🩹 Preventing skin injury is essential to avoid infection and urethral trauma.

🩹 A patient with fragile skin, edema, or rashes may not be a good candidate for external catheter use.

🩹 Prioritizing skin safety follows the ABC/Safety nursing prioritization model.

Why the Incorrect Answers Are Wrong

❌ Patient preference

🚫 Important but not the highest priority when safety is at risk.

❌ Frequency of incontinence

🚫 Frequency helps determine need, but skin safety still outweighs it.

❌ Ability to apply the catheter independently

🚫 Helpful for teaching, but not the deciding factor for safe use.

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Answer 9

Correct Answers:

Reassess the patient's pain level and check for any additional symptoms.

Rationale :

🩺 Reassessing pain is a required nursing step when treatment is ineffective—this ensures the nurse evaluates response to the medication.

🩺 Pain may indicate complications such as bleeding, infection, or medication failure, which reassessment helps detect.

🩺 Reassessment guides whether the nurse should notify the provider, escalate care, or offer alternative interventions.

🩺 It aligns with the nursing process (ADPIE): Interventions must be followed by reassessment.

🩺 This ensures patient safety and effective relief rather than guessing or assuming.

Why the Incorrect Answers Are Wrong

❌ Administer a higher dose

🚫 Unsafe and beyond nurse’s scope without a new order.

❌ Document and wait

🚫 Delays care and leaves patient in unmanaged pain.

❌ Suggest deep breathing exercises

🚫 Adjunct, but not appropriate if pain medication failed and patient still reports severe pain.

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Answer 10

Correct Answers:

Milk

Rationale :

🥛 “Galact” is a medical root meaning milk.

🥛 Found in terms like galactorrhea (milk flow) and galactose (milk sugar).

🥛 Commonly used in endocrinology, pediatrics, and postpartum care.

🥛 Helps describe conditions involving lactation or milk production.

🥛 Recognizing this root aids in interpreting breastfeeding and endocrine terminology.

Why the Incorrect Answers Are Wrong

❌ Flesh — 🚫 Root is sarco-.

❌ Birth — 🚫 Root is nat/o.

❌ Plate — 🚫 Root for plaque/plate is plak- or phak- depending on context.

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Custom N1100 Fall 25 Exam 4

No.

1 :
A student nurse is assessing a patient's food choices as part of a nutritional assessment. Which of the following actions is MOST appropriate to identify potential dietary risk factors?

2 :
A patient who has recently undergone abdominal surgery is being taught how to use an incentive spirometer. What should the nurse ensure the patient understands to effectively use the device?

3 :
A nurse is performing a skin assessment on a patient who has been using a nasal cannula for oxygen therapy. Which finding indicates a need for immediate intervention?

5 :
A nurse is assessing a patient with a new colostomy. Which finding would indicate a complication that requires immediate intervention?

6 :
A patient with diabetes has been admitted for wound care management. Who are part of the healthcare team involved in the patient's care? (Select all that apply)

7 :
Medical Terminology: What does "andr" mean?

8 :
A nurse is caring for a male patient with urinary incontinence and is considering the use of an external catheter. Which factor would the nurse PRIORITIZE when deciding to use an external catheter for this patient?

9 :
A patient reports a pain level of 8 out of 10 after surgery. The nurse administers the prescribed analgesic, but the patient continues to report pain. What should be the nurse's NEXT action?

10 :
Medical Terminology: What does "galact" mean?

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Custom N1100 Fall 25 Exam 4

No.

1 : A student nurse is assessing a patient's food choices as part of a nutritional assessment. Which of the following actions is MOST appropriate to identify potential dietary risk factors?

2 : A patient who has recently undergone abdominal surgery is being taught how to use an incentive spirometer. What should the nurse ensure the patient understands to effectively use the device?

3 : A nurse is performing a skin assessment on a patient who has been using a nasal cannula for oxygen therapy. Which finding indicates a need for immediate intervention?

5 : A nurse is assessing a patient with a new colostomy. Which finding would indicate a complication that requires immediate intervention?

6 : A patient with diabetes has been admitted for wound care management. Who are part of the healthcare team involved in the patient's care? (Select all that apply)

7 : Medical Terminology: What does "andr" mean?

8 : A nurse is caring for a male patient with urinary incontinence and is considering the use of an external catheter. Which factor would the nurse PRIORITIZE when deciding to use an external catheter for this patient?

9 : A patient reports a pain level of 8 out of 10 after surgery. The nurse administers the prescribed analgesic, but the patient continues to report pain. What should be the nurse's NEXT action?

10 : Medical Terminology: What does "galact" mean?

1 :
A student nurse is assessing a patient's food choices as part of a nutritional assessment. Which of the following actions is MOST appropriate to identify potential dietary risk factors?

2 :
A patient who has recently undergone abdominal surgery is being taught how to use an incentive spirometer. What should the nurse ensure the patient understands to effectively use the device?

3 :
A nurse is performing a skin assessment on a patient who has been using a nasal cannula for oxygen therapy. Which finding indicates a need for immediate intervention?

5 :
A nurse is assessing a patient with a new colostomy. Which finding would indicate a complication that requires immediate intervention?

6 :
A patient with diabetes has been admitted for wound care management. Who are part of the healthcare team involved in the patient's care? (Select all that apply)

7 :
Medical Terminology: What does "andr" mean?

8 :
A nurse is caring for a male patient with urinary incontinence and is considering the use of an external catheter. Which factor would the nurse PRIORITIZE when deciding to use an external catheter for this patient?

9 :
A patient reports a pain level of 8 out of 10 after surgery. The nurse administers the prescribed analgesic, but the patient continues to report pain. What should be the nurse's NEXT action?

10 :
Medical Terminology: What does "galact" mean?