Lewis’s Medical-Surgical Nursing in Canada 4th , 5thEdition by
Jane Tyerman Test Bank
Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin
supplementation?
a. Glossitis
b. Ecchymoses
c. Dry, scaly skin
d. Gingival swelling - ANSWER: ANS: A
Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at
risk for signs of cobalamin deficiency, such as glossitis, anorexia, sore mouth and tongue, pallor,
neurologic problems (e.g., depression, dizziness), weight loss, nausea, constipation, and anemia. The
other symptoms listed are associated with other nutritional deficiencies but would not be associated
with a vegan diet.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment
MSC:NCLEX: PhysiologicalIntegrity
A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being
admitted. Which assessment finding would the nurse expect?
a. Restlessness
b. Hypertension
c. Pitting edema
d. Food allergies - ANSWER: ANS: C
Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure
and level of consciousness are not directly affected by malnutrition. Food allergies are not an
indicator of nutritional status.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX:
PhysiologicalIntegrity
Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose
high-calorie, high-protein foods?
a. Baked fish with applesauce
b. Beef noodle soup and canned corn
c. Fresh fruit salad with yogurt topping
d. Fried chicken with potatoes and gravy - ANSWER: ANS: D
Foods that are high in calories include fried foods and those covered with sauces. High-protein foods
include meat and dairy products. The other choices are lower in calories and protein.
DIF:CognitiveLevel: Analyze (Analysis) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Evaluation
A patient has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum
transferrin and albumin levels. What should the nurse encourage the patient to increase in the diet?
a. Iron
b. Protein
c. Calories
,d. Carbohydrate - ANSWER: ANS: B The patient's C-reactive protein and transferrin levels indicate low
protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do
not indicate a need for increased carbohydrate or iron intake.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Planning
A patient who has just been started on enteral nutrition of full-strength formula at 100 mL/hr has 6
liquid stools the first day. Which action would the nurse plan to take?
a. Slow the infusion rate of the feeding.
b. Check gastric residual volumes more often.
c. Change the enteral feeding system and formula every 8 hours.
d. Discontinue administration of water through the feeding tube. - ANSWER: ANS: A
Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or
decrease the concentration of the feeding. Water should be given when patients receive enteral
feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and
formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Planning
A young adult with extensive facial injuries from a motor vehicle crash is receiving continuous enteral
nutrition through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include
in the plan of care?
a. Keep the patient positioned lying on the left side.
b. Flush the tube with 30 mL of water every 4 hours.
c. Crush and mix medications in with the feeding formula.
d. Obtain a daily abdominal radiograph to verify tube placement. - ANSWER: ANS: B
The tube is flushed every 4 hours during continuous feedings to avoid tube obstruction. The patient
should be positioned with the head of the bed elevated. Crushed medications mixed in with the
formula are likely to clog the tube. An x-ray is obtained immediately after placement of the PEG tube
to check position, but daily x-rays are not needed.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Planning
A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and
dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that
about 50 mL remain in the PN container. Which action would the nurse take?
a. Add a new container of PN using the current tubing and filter.
b. Hang a new container of PN and change the IV tubing and filter.
c. Infuse the remaining 50 mL and then hang a new container of PN.
d. Ask the health care provider to clarify the written PN prescription. - ANSWER: ANS: B
All PN solutions and tubings are changed at 24 hours. Infusion of the additional 50 mL will increase
patient risk for infection. The nurse (not the health care provider) is responsible for knowing the
indicated times for tubing and filter changes.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX:
PhysiologicalIntegrity
A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral
nutrition (PN) infusion. Which action would the nurse take?
a. Obtain a venous blood glucose specimen.
, b. Slow the infusion rate of the PN infusion.
c. Recheck the blood glucose level in 4 to 6 hours.
d. Contact the health care provider for infusion rate changes. - ANSWER: ANS: C
Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing
monitoring. Because the glucose elevation is small and expected, infusion rate changes are not
needed. There is no need to obtain a venous specimen for comparison. Slowing the rate of the
infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX:
PhysiologicalIntegrity
After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition
(PN). Which data is the best indicator that the patient is receiving adequate nutrition?
a. Serum albumin level is 3.5 mg/dL.
b. Fluid intake and output are balanced.
c. Surgical incision is healing normally.
d. Blood glucose is less than 110 mg/dL. - ANSWER: ANS: C
Because poor wound healing is a possible complication of malnutrition for this patient, normal healing
of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood
glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does
not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do
not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect
adequate caloric intake, which is also important for the patient.
DIF:CognitiveLevel: Analyze (Analysis) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Evaluation
A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little
and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in
improving the patient's oral intake?
a. Order six small meals daily.
b. Make a referral to the dietitian.
c. Teach the patient about high-calorie foods.
d. Ask family members to bring favorite foods. - ANSWER: ANS: D
The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked
foods might improve intake. The other interventions may also help improve the patient's intake, but
the most effective action will be to offer the patient more appealing foods.
DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Implementation MSC:NCLEX:
PhysiologicalIntegrity
What action would the nurse take when caring for a patient with a soft, silicone nasogastric tube in
place for enteral nutrition?
a. Avoid giving medications through the feeding tube.
b. Keep head of bed elevated to 30- to 45-degree angle
c. Replace the tube every 3 days to avoid mucosal damage.
d. Administer medications mixed with enteral feeding formula. - ANSWER: ANS: B
Elevate the head of the bed to decrease the risk of aspiration. The tubes are less likely to cause
mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need
to be replaced at certain intervals. Medications can be given through these tubes but flushing before
and after medication administration is important to avoid clogging. Do not mix medications with
formula, as the combination can clog the tube.
Jane Tyerman Test Bank
Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin
supplementation?
a. Glossitis
b. Ecchymoses
c. Dry, scaly skin
d. Gingival swelling - ANSWER: ANS: A
Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at
risk for signs of cobalamin deficiency, such as glossitis, anorexia, sore mouth and tongue, pallor,
neurologic problems (e.g., depression, dizziness), weight loss, nausea, constipation, and anemia. The
other symptoms listed are associated with other nutritional deficiencies but would not be associated
with a vegan diet.
DIF:CognitiveLevel: Apply (Application)
TOP: NursingProcess: Assessment
MSC:NCLEX: PhysiologicalIntegrity
A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being
admitted. Which assessment finding would the nurse expect?
a. Restlessness
b. Hypertension
c. Pitting edema
d. Food allergies - ANSWER: ANS: C
Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure
and level of consciousness are not directly affected by malnutrition. Food allergies are not an
indicator of nutritional status.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX:
PhysiologicalIntegrity
Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose
high-calorie, high-protein foods?
a. Baked fish with applesauce
b. Beef noodle soup and canned corn
c. Fresh fruit salad with yogurt topping
d. Fried chicken with potatoes and gravy - ANSWER: ANS: D
Foods that are high in calories include fried foods and those covered with sauces. High-protein foods
include meat and dairy products. The other choices are lower in calories and protein.
DIF:CognitiveLevel: Analyze (Analysis) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Evaluation
A patient has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum
transferrin and albumin levels. What should the nurse encourage the patient to increase in the diet?
a. Iron
b. Protein
c. Calories
,d. Carbohydrate - ANSWER: ANS: B The patient's C-reactive protein and transferrin levels indicate low
protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do
not indicate a need for increased carbohydrate or iron intake.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Planning
A patient who has just been started on enteral nutrition of full-strength formula at 100 mL/hr has 6
liquid stools the first day. Which action would the nurse plan to take?
a. Slow the infusion rate of the feeding.
b. Check gastric residual volumes more often.
c. Change the enteral feeding system and formula every 8 hours.
d. Discontinue administration of water through the feeding tube. - ANSWER: ANS: A
Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or
decrease the concentration of the feeding. Water should be given when patients receive enteral
feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and
formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Planning
A young adult with extensive facial injuries from a motor vehicle crash is receiving continuous enteral
nutrition through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include
in the plan of care?
a. Keep the patient positioned lying on the left side.
b. Flush the tube with 30 mL of water every 4 hours.
c. Crush and mix medications in with the feeding formula.
d. Obtain a daily abdominal radiograph to verify tube placement. - ANSWER: ANS: B
The tube is flushed every 4 hours during continuous feedings to avoid tube obstruction. The patient
should be positioned with the head of the bed elevated. Crushed medications mixed in with the
formula are likely to clog the tube. An x-ray is obtained immediately after placement of the PEG tube
to check position, but daily x-rays are not needed.
DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Planning
A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and
dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that
about 50 mL remain in the PN container. Which action would the nurse take?
a. Add a new container of PN using the current tubing and filter.
b. Hang a new container of PN and change the IV tubing and filter.
c. Infuse the remaining 50 mL and then hang a new container of PN.
d. Ask the health care provider to clarify the written PN prescription. - ANSWER: ANS: B
All PN solutions and tubings are changed at 24 hours. Infusion of the additional 50 mL will increase
patient risk for infection. The nurse (not the health care provider) is responsible for knowing the
indicated times for tubing and filter changes.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX:
PhysiologicalIntegrity
A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral
nutrition (PN) infusion. Which action would the nurse take?
a. Obtain a venous blood glucose specimen.
, b. Slow the infusion rate of the PN infusion.
c. Recheck the blood glucose level in 4 to 6 hours.
d. Contact the health care provider for infusion rate changes. - ANSWER: ANS: C
Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing
monitoring. Because the glucose elevation is small and expected, infusion rate changes are not
needed. There is no need to obtain a venous specimen for comparison. Slowing the rate of the
infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.
DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX:
PhysiologicalIntegrity
After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition
(PN). Which data is the best indicator that the patient is receiving adequate nutrition?
a. Serum albumin level is 3.5 mg/dL.
b. Fluid intake and output are balanced.
c. Surgical incision is healing normally.
d. Blood glucose is less than 110 mg/dL. - ANSWER: ANS: C
Because poor wound healing is a possible complication of malnutrition for this patient, normal healing
of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood
glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does
not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do
not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect
adequate caloric intake, which is also important for the patient.
DIF:CognitiveLevel: Analyze (Analysis) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess:
Evaluation
A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little
and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in
improving the patient's oral intake?
a. Order six small meals daily.
b. Make a referral to the dietitian.
c. Teach the patient about high-calorie foods.
d. Ask family members to bring favorite foods. - ANSWER: ANS: D
The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked
foods might improve intake. The other interventions may also help improve the patient's intake, but
the most effective action will be to offer the patient more appealing foods.
DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Implementation MSC:NCLEX:
PhysiologicalIntegrity
What action would the nurse take when caring for a patient with a soft, silicone nasogastric tube in
place for enteral nutrition?
a. Avoid giving medications through the feeding tube.
b. Keep head of bed elevated to 30- to 45-degree angle
c. Replace the tube every 3 days to avoid mucosal damage.
d. Administer medications mixed with enteral feeding formula. - ANSWER: ANS: B
Elevate the head of the bed to decrease the risk of aspiration. The tubes are less likely to cause
mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need
to be replaced at certain intervals. Medications can be given through these tubes but flushing before
and after medication administration is important to avoid clogging. Do not mix medications with
formula, as the combination can clog the tube.
