NURS 235 Exam 3: Questions With Verified Solutions
A nurse is evaluating a patient following the administration of an enteral
feeding. Which findings are normal and are criteria that indicate patient
tolerance to the feeding? Select all that apply.
a.Absence of nausea, vomiting
b.weight gain
c.Bowel sounds within normal range
d. Large amount of gastric residue
e.Absence of diarrhea and constipation
f.Slight abdominal pain and distention Right Ans - A,C,E
A nurse is calculating the body mass index (BMI) of a 35-year-old male patient
who is extremely obese. The patient's height is 5′6″ and his current weight is
325 lb. What would the nurse document as his BMI?
a.50.5
b. 52.4
c.54.5
d. 55.2 Right Ans - B.52.4
A nurse is feeding an older adult patient who has dementia. Which
intervention should the nurse perform to facilitate this process?
A.Stroke the underside of the patient's chin to promote swallowing. B.Serve
meals in different places and at different times.
C. Offer a whole tray of various foods to choose from.
D.Avoid between-meal snacks to ensure hunger at mealtime. Right Ans - A
A patient who has COPD is refusing to eat. Which intervention would be most
helpful in stimulating appetite in this patient?
A.Administering pain medication after meals.
B.Encouraging food from home when possible.
C. Scheduling his respiratory therapy before each meal.
D.Reinforcing the importance of his eating exactly what is delivered to him.
Right Ans - B
,A nurse is feeding a patient who is experiencing dysphagia. Which nursing
intervention would the nurse initiate for this patient?
A.Feed the patient solids first and then liquids last.
B.Place the head of the bed at a 30-degree angle during feeding. C.Puree all
foods to a liquid consistency.
D.Provide a 30-minute rest period prior to mealtime. Right Ans - D
A nurse is feeding a patient who states that she is feeling nauseated and can't
eat what is being offered. What would be the most appropriate initial action of
the nurse in this situation?
A.Remove the tray from the room.
B.Administer an antiemetic and encourage the patient to take small amounts.
C.Explore with the patient why she does not want to eat her food.
D.Offer high-calorie snacks such as pudding and ice cream. Right Ans - A
A nurse is evaluating patients to determine their need for parenteral nutrition
(PN). Which patients would be the best candidates for this type of nutritional
support? Select all that apply.
A.A patient with irritable bowel syndrome who has intractable diarrhea
B.A patient with celiac disease not absorbing nutrients from the GI tract
C.A patient who is underweight and needs short-term nutritional support
D.A patient who is comatose and needs long-term nutritional support E.A
patient who has anorexia and refuses to take foods via the oral route
F.A patient with burns who has not been able to eat adequately for 5 days
Right Ans - A,B,F
A patient has been admitted to the alcoholic referral unit in the local hospital.
Based on an understanding of the effects of alcohol on the GI tract, which is a
priority concern related to nutrition?
A. Vitamin B malnutrition
B.Obesity
C.Dehydration
D.Vitamin C deficiency Right Ans - A
, A nurse is caring for a newly placed gastrostomy tube of a postoperative
patient. Which nursing action is performed correctly?
A.The patient consumed 75% of the liquids on her breakfast tray.
B.The patient tells you she is hungry.
C.The patient's abdomen is soft, nondistended, with bowel sounds.
D.The patient reports fullness and diarrhea after breakfast. Right Ans - D
A patient who is moved to a hospital bed following throat surgery is ordered
to receive continuous tube feedings through a small-bore nasogastric tube.
Following placement of the tube, which nursing action would the nurse
initiate to ensure correct placement of the tube?
A.Auscultate the bowel sounds.
B.Measure the gastric aspirate pH.
C.Measure the amount of residual in the tube.
D.Obtain an order for a radiographic examination of the tube. Right Ans - D
Which nursing diagnosis would be most appropriate for a patient with a body
mass index (BMI) of 18?
A.Malabsorption
B.Anemia
C.Protein depletion
D. Reduction in total muscle mass Right Ans - D
A nurse is administering a tube feeding for a patient who is post bowel
surgery. When attempting to aspirate the contents, the nurse notes that the
tube is clogged. What would be the nurse's next action following this
assessment?
A.Use warm water or air and gentle pressure to remove the clog.
B.Use a stylet to unclog the tubes.
C.Administer cola to remove the clog.
D.Replace the tube with a new one. Right Ans - A
A nurse performs presurgical assessments of patients in an ambulatory care
center. Which patient would the nurse report to the surgeon as possibly
needing surgery to be postponed?
A nurse is evaluating a patient following the administration of an enteral
feeding. Which findings are normal and are criteria that indicate patient
tolerance to the feeding? Select all that apply.
a.Absence of nausea, vomiting
b.weight gain
c.Bowel sounds within normal range
d. Large amount of gastric residue
e.Absence of diarrhea and constipation
f.Slight abdominal pain and distention Right Ans - A,C,E
A nurse is calculating the body mass index (BMI) of a 35-year-old male patient
who is extremely obese. The patient's height is 5′6″ and his current weight is
325 lb. What would the nurse document as his BMI?
a.50.5
b. 52.4
c.54.5
d. 55.2 Right Ans - B.52.4
A nurse is feeding an older adult patient who has dementia. Which
intervention should the nurse perform to facilitate this process?
A.Stroke the underside of the patient's chin to promote swallowing. B.Serve
meals in different places and at different times.
C. Offer a whole tray of various foods to choose from.
D.Avoid between-meal snacks to ensure hunger at mealtime. Right Ans - A
A patient who has COPD is refusing to eat. Which intervention would be most
helpful in stimulating appetite in this patient?
A.Administering pain medication after meals.
B.Encouraging food from home when possible.
C. Scheduling his respiratory therapy before each meal.
D.Reinforcing the importance of his eating exactly what is delivered to him.
Right Ans - B
,A nurse is feeding a patient who is experiencing dysphagia. Which nursing
intervention would the nurse initiate for this patient?
A.Feed the patient solids first and then liquids last.
B.Place the head of the bed at a 30-degree angle during feeding. C.Puree all
foods to a liquid consistency.
D.Provide a 30-minute rest period prior to mealtime. Right Ans - D
A nurse is feeding a patient who states that she is feeling nauseated and can't
eat what is being offered. What would be the most appropriate initial action of
the nurse in this situation?
A.Remove the tray from the room.
B.Administer an antiemetic and encourage the patient to take small amounts.
C.Explore with the patient why she does not want to eat her food.
D.Offer high-calorie snacks such as pudding and ice cream. Right Ans - A
A nurse is evaluating patients to determine their need for parenteral nutrition
(PN). Which patients would be the best candidates for this type of nutritional
support? Select all that apply.
A.A patient with irritable bowel syndrome who has intractable diarrhea
B.A patient with celiac disease not absorbing nutrients from the GI tract
C.A patient who is underweight and needs short-term nutritional support
D.A patient who is comatose and needs long-term nutritional support E.A
patient who has anorexia and refuses to take foods via the oral route
F.A patient with burns who has not been able to eat adequately for 5 days
Right Ans - A,B,F
A patient has been admitted to the alcoholic referral unit in the local hospital.
Based on an understanding of the effects of alcohol on the GI tract, which is a
priority concern related to nutrition?
A. Vitamin B malnutrition
B.Obesity
C.Dehydration
D.Vitamin C deficiency Right Ans - A
, A nurse is caring for a newly placed gastrostomy tube of a postoperative
patient. Which nursing action is performed correctly?
A.The patient consumed 75% of the liquids on her breakfast tray.
B.The patient tells you she is hungry.
C.The patient's abdomen is soft, nondistended, with bowel sounds.
D.The patient reports fullness and diarrhea after breakfast. Right Ans - D
A patient who is moved to a hospital bed following throat surgery is ordered
to receive continuous tube feedings through a small-bore nasogastric tube.
Following placement of the tube, which nursing action would the nurse
initiate to ensure correct placement of the tube?
A.Auscultate the bowel sounds.
B.Measure the gastric aspirate pH.
C.Measure the amount of residual in the tube.
D.Obtain an order for a radiographic examination of the tube. Right Ans - D
Which nursing diagnosis would be most appropriate for a patient with a body
mass index (BMI) of 18?
A.Malabsorption
B.Anemia
C.Protein depletion
D. Reduction in total muscle mass Right Ans - D
A nurse is administering a tube feeding for a patient who is post bowel
surgery. When attempting to aspirate the contents, the nurse notes that the
tube is clogged. What would be the nurse's next action following this
assessment?
A.Use warm water or air and gentle pressure to remove the clog.
B.Use a stylet to unclog the tubes.
C.Administer cola to remove the clog.
D.Replace the tube with a new one. Right Ans - A
A nurse performs presurgical assessments of patients in an ambulatory care
center. Which patient would the nurse report to the surgeon as possibly
needing surgery to be postponed?
