Test Bank Complete_ Lewis’s Medical-Surgical Nursing
in Canada, 5th Edition, Mariann M. Harding (Author),
Jane Tyerman (Author), Shelley Cobbett (Author) All
Chapter 1-72 (2024/2055) Latest Edition
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 - ANSWERANS: 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 - ANSWERANS: 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 - ANSWERANS: 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 - ANSWERANS: 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. - ANSWERANS: 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. - ANSWERANS: 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. - ANSWERANS:
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. - ANSWERANS: 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.
in Canada, 5th Edition, Mariann M. Harding (Author),
Jane Tyerman (Author), Shelley Cobbett (Author) All
Chapter 1-72 (2024/2055) Latest Edition
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 - ANSWERANS: 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 - ANSWERANS: 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 - ANSWERANS: 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 - ANSWERANS: 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. - ANSWERANS: 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. - ANSWERANS: 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. - ANSWERANS:
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. - ANSWERANS: 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.
