QUESTIONS AND ANSWERS WITH RATIONALES BEST
GRADED A+ NEW UPDATE 2023|2024
A nurse is teaching a prenatal education class about breastfeeding.
Which of the following instructions should the nurse include in the
teaching?
a. Plan 5-min feedings on each breast on the first day after birth
i. Rationale: The nurse should instruct the clients to let the
newborn nurse for 5 min on each breast on the first day to
promote milk production.
A nurse is assessing a client who has type 2 diabetes mellitus. The nurse
should recognize which of the following as a manifestation of hypoglycemia?
a. Confusion
i. Rationale: The nurse should recognize confusion as a
manifestation of hypoglycemia.
A nurse is teaching a client who is newly diagnosed with type 1 diabetes
mellitus how to count carbohydrates. Which of the following statements
made by the client indicates an understanding of the teaching?
a. “I know the serving size can affect the number of carbohydrates I eat.”
i. Rationale: The nurse should instruct the client that the
portion size affects the number of carbohydrates
A nurse is assessing a client who is suspected of having lactose intolerance.
Which of the following is an expected finding?
a. Flatulence
i. Rationale: Flatulence, bloating, and cramping, and diarrhea are
expected findings associated with lactose intolerance.
, A nurse is performing a cultural nursing assessment for a client whose
religious practices include fasting 1 day each week. Which of the following
questions should the nurse ask the client? (Select all that apply.)
a. “Are you exempt from fasting during illness?”
b. “Does fasting mean refraining from drinking liquids?”
c.“Does your fasting occur during certain hours of the day?”
d. “Does fasting mean eating only a certain type of food?”
A nurse is planning dietary teaching for a client who has dumping syndrome
following a gastrectomy. Which of the following interventions should the
nurse include in the client's plan of care?
a. Select grains with less than 2 g fiber per serving
i. Rationale: Clients at risk for dumping syndrome better tolerate
low-fiber grains that contain less than 2 g fiber per serving to
slow gastric emptying.
A nurse is assessing a client's risk for pressure injuries using the Braden scale.
The client eats more than half of most meals but occasionally refuses a meal.
Which of the following information should the nurse document on the
nutrition category of the Braden scale?
a. 3 (adequate)
i. Rationale: A client who eats more than half of most meals,
occasionally refuses a meal, and has four servings of protein
each day scores a 3 (Adequate) in the nutrition category of the
Braden scale.
ii. 1 (Very Poor) – A client who scores a 1 (Very Poor) in the
nutrition category of the Braden scale never finishes a complete
meal, drinks little fluid, and does not drink any dietary
supplements.
iii. 2 (Probably Inadequate) – A client who scores a 2 (Probably
, Inadequate) in the nutrition category of the Braden scale only
eats about half of meals or snacks and only occasionally takes
dietary supplements.
iv. 4 (Excellent) – A client who scores a 4 (Excellent) in the nutrition
category of the Braden scale eats most of every meal, eats
plenty of protein, and occasionally eats between meals.
A nurse is providing teaching about lowering solid fat intake to an
adolescent client who usually consumes about 2,000 calories per day.
Which of the following instructions should the nurse include?
a. “Restrict your daily meat intake to 5 ounces.”
i. Rationale: The nurse should instruct the client to limit meat
intake to about 5 oz per day. A meat portion should be no larger
than the size of a deck of cards
A home health nurse is reviewing the medical record of a client who had an
open reduction internal fixation of the tibia. Which of the following findings
should the nurse identify as a risk factor for impaired would healing?
a. The client consumes 1,000 kcal daily
i. Rationale: Adults who have had surgery require at least 1,500
kcal daily to meet energy needs and build protein for tissue
healing. The nurse should recognize that a 1,000 kcal/day intake
is below the client's needs.
A nurse is providing teaching to a client who has dumping syndrome.
Which of the following information should the nurse include?
a. Apply pectin to foods
i. Rationale: The client should apply pectin, a dietary fiber that
helps to delay gastric emptying, to foods.
A nurse in a long-term care facility is monitoring a client during mealtime
, who has Parkinson's disease. Which of the following findings should the
nurse identify as the priority?
a. The client drools while eating
i. Rationale: Drooling while eating can indicate that this client is
at greatest risk for aspiration of food from dysphagia, which
can lead to pulmonary complications; therefore, the nurse
should identify this as the priority finding.