NURS 225 EXAM 2 QUESTIONS & ANSWERS
Important nutrients that aid in the healing of wounds - answers :protein- tested by
checking albumin
Cultural considerations when educating a patient on a proper diet - answers :adopt their
preferences, accommodate their preferences in keeping with their culutre
What are the common bacteria and foods that can lead to food poisioning? - answers :e
coli, undercooked, raw or spoiled meat or eggs
What is the proper diet for a patent with heart disease? - answers :low salt, low fat, low
carbs
Why does someone with heart disease have altered nutrition? - answers :- decreased
hunger, fatigue, shortness of breathe
What is the proper diet for a patient with diabetes? - answers :carb control
How many grams are in protein, carbs, fat? - answers :4, 4, 9
Who is at risk for altered nutrition? - answers :elderly living alone, inability to chew-
denture problems, body image issues, npo due to illness or surgery. Stroke with
weakness or dysphagia
The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings.
What is the correct order of steps to perform this procedure?
1. Place patient in high-fowler's position.
2. Have patient flex head toward chest.
3. Assess patient's gag reflex.
4. Determine length of the tube to be inserted.
5. Obtain radiological confirmation of tube placement.
6. Check ph of gastric aspirate for verifying placement.
7. Identify patient with two identifiers. - answers :7, 1, 3, 4, 2, 5, 6
A patient's gastric residual volume was 250 ml at 0800 and 350 ml at 1200. What is the
appropriate nursing action?
1. Assess bowel sounds
2. Raise the head of the bed to at least 45 degrees
3.position the patient on his or her right side to promote stomach emptying
4. Do not reinstall aspirate and hold the feeding until you talk to the primary care
provider - answers :4
The nurse would delegate which of the following to nursing assistive personnel (nap)?
(select all that apply.)
1. Repositioning and retaping a patient's nasogastric tube
,2. Performing glucose monitoring every 6 hours on a patient
3. Documenting po intake on a patient who is on a calorie count for 72 hours
4. Administering enteral feeding bolus after tube placement has been verified
5. Hanging a new bag of enteral feeding - answers :2, 3
The patient's blood glucose level is 330 mg/dl. What is the priority nursing intervention?
1. Recheck by performing another blood glucose test.
2. Call the primary health care provider.
3. Check the medical record to see if there is a medication order for abnormal glucose
levels.
4. Monitor and recheck in 2 hours. - answers :3
Which statement made by a patient of a 2-month-old infant requires further education?
1. I'll continue to use formula for the baby until he is a least a year old.
2. I'll make sure that i purchase iron-fortified formula.
3. I'll start feeding the baby cereal at 4 months.
4. I'm going to alternate formula with whole milk starting next month. - answers :4
The nurse is teaching a program on healthy nutrition at the senior community center.
Which points should be included in the program for older adults? (select all that apply.)
1. Avoid grapefruit and grapefruit juice, which impair drug absorption.
2. Increase the amount of carbohydrates for energy.
3. Take a multivitamin that includes vitamin d for bone health.
4. Cheese and eggs are good sources of protein.
5. Limit fluids to decrease the risk of edema. - answers :1, 3, 4
The nurse sees the nursing assistive personnel (nap) perform the following intervention
for a patient receiving continuous enteral feedings. Which action would require
immediate attention?
1. Fastening tube to the gown with new tape
2. Placing patient supine while giving a bath
3. Hanging a new container of enteral feeding
4. Ambulating patient with enteral feedings still infusing - answers :2
A patient is receiving total parenteral nutrition (tpn). What is the primary intervention the
nurse should follow to prevent a central line infection?
1. Institute isolation precautions
2. Clean the central line port through which the tpn is infusing with alcohol
3. Change the tpn tubing every 24 hours
4. Monitor glucose levels to watch and assess for glucose intolerance - answers :2
Which patients are at high risk for nutritional deficits? (select all that apply.)
1. The divorced computer programmer who eats precooked food from the local
restaurant
2. The middle-age female with celiac disease who does not follow her gluten-free diet
,3. The 45-year-old patient with type ii diabetes who monitors her carbohydrate intake
and exercises regularly
4. The 25-year-old patient with crohn's disease who follows a strict diet but does not
take vitamins or iron supplements
5. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and
protein levels are normal - answers :2, 4
What factors lead to impaired skin integrity and breakdown? - answers :immobility, poor
appetite, moisture/ sweating, shearing and friction, decreased loc, tissue perfusion, age,
infection
Methods a nurse uses to assess wounds/ infection/ healing - answers :appearance of
wounds, smell, discharge, color, swelling, measure of wound
Important nutrient for wound healing? How to test for it? - answers :protein, test for
albumin
Other names for pressure ulcer - answers :pressure ulcer, pressure sore, decubitus
ulcer and bedsore. They all mean impaired skin integrity r/t unrelieved prolonged
pressure
What is the difference in a partial thickness and full thickness wound? How do they
heal? - answers :partial: only partial loss of skin layers (the epidermis and superficial
dermal layers). Heals by regeneration
Full: total loss of the skin layer. Heals by forming new tissue (takes longer than partial to
heal which means there is a greater risk for infections in these kinds of wounds)
What are some complications of wound healing? - answers :hematoma- collection of
blood under tissue
Dehiscence- separation of wound layers
Hemorrhage- bleeding from a wound site
Evisceration- visceral organs profuse through the wound opening
The nurse is caring for a patient with pneumonia who has severe malnutrition. The
nurse recognizes that, because of the nutritional status, the patient is at increased risk
for:(select all that apply)
1. Heart disease
2. Sepsis
3. Pleural effusion
4. Cardiac arrhythmias
5. Diarrhea - answers :2, 3, 4
The nurse evaluates which laboratory values to assess a patents potential for wound
healing?
1. Fluid status
2. Potassium
, 3. Lipids
4. Nitrogen balance - answers :4
The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet
when she begins to choke. What is the priority nursing intervention?
1. Suction her mouth and through
2. Turn her on her side
3. Put on oxygen at 2-l nasal cannula
4. Stop feeding her and place on npo - answers :4
A patient who is receiving parenteral nutrition (pn) through a central veinous catheter
has an air embolus. What would the nurse do first?
1. Have the patient perform a valsalva maneuver
2. Clamp the iv tubing to prevent more air from entering the line
3. Have the patient take a deep breath and hold it
4. Notify the health care provider immediately - answers :1
A patient is receiving both parenteral (pn) and enteral nutrition (en). When would the
nurse collaborate with the hcp and request discontinuing pn?
1. When 25% of the patients nutritional needs are met by the tube feedings
2. When bowel sounds return
3. When the central line has been in for 10 days
4. When 75% of the patients nutritional needs are met by the tube feeding - answers :4
The nurse is educating the patient and his family about the parenteral nutrition. Which
aspect related to this form of nutrition would be appropriate to include? (select all that
apply)
1. The purpose of the fat emulsion in parenteral nutrition is to prevent deficiency in
essential fatty acids
2. We can give you perenteral nutrition through your peripheral iv line to prevent further
infection
3. The fat emulsion will help control hyperglycemia during periods of stress
4. The parenteral nutrition will help your wounds heal
5. Since we just started the pn, we will only infuse 50% of your daily needs for the next
6 hours - answers :1, 3, 4
What are the economic consequences of a pressure ulcer? - answers :hospitals do not
get reimbursed for a stage 3 or 4 pressure ulcer that occurs while hospitalized. Also a
pressure ulcer increases the duration of a patients stay which costs more money for
them
What are some implementations for pressure ulcers? - answers :topical skin care,
incontinence management, protect bony prominences, skin barriers for incontinence,
rotate patient, decrease the amount of pressure exerted over bony prominences
Important nutrients that aid in the healing of wounds - answers :protein- tested by
checking albumin
Cultural considerations when educating a patient on a proper diet - answers :adopt their
preferences, accommodate their preferences in keeping with their culutre
What are the common bacteria and foods that can lead to food poisioning? - answers :e
coli, undercooked, raw or spoiled meat or eggs
What is the proper diet for a patent with heart disease? - answers :low salt, low fat, low
carbs
Why does someone with heart disease have altered nutrition? - answers :- decreased
hunger, fatigue, shortness of breathe
What is the proper diet for a patient with diabetes? - answers :carb control
How many grams are in protein, carbs, fat? - answers :4, 4, 9
Who is at risk for altered nutrition? - answers :elderly living alone, inability to chew-
denture problems, body image issues, npo due to illness or surgery. Stroke with
weakness or dysphagia
The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings.
What is the correct order of steps to perform this procedure?
1. Place patient in high-fowler's position.
2. Have patient flex head toward chest.
3. Assess patient's gag reflex.
4. Determine length of the tube to be inserted.
5. Obtain radiological confirmation of tube placement.
6. Check ph of gastric aspirate for verifying placement.
7. Identify patient with two identifiers. - answers :7, 1, 3, 4, 2, 5, 6
A patient's gastric residual volume was 250 ml at 0800 and 350 ml at 1200. What is the
appropriate nursing action?
1. Assess bowel sounds
2. Raise the head of the bed to at least 45 degrees
3.position the patient on his or her right side to promote stomach emptying
4. Do not reinstall aspirate and hold the feeding until you talk to the primary care
provider - answers :4
The nurse would delegate which of the following to nursing assistive personnel (nap)?
(select all that apply.)
1. Repositioning and retaping a patient's nasogastric tube
,2. Performing glucose monitoring every 6 hours on a patient
3. Documenting po intake on a patient who is on a calorie count for 72 hours
4. Administering enteral feeding bolus after tube placement has been verified
5. Hanging a new bag of enteral feeding - answers :2, 3
The patient's blood glucose level is 330 mg/dl. What is the priority nursing intervention?
1. Recheck by performing another blood glucose test.
2. Call the primary health care provider.
3. Check the medical record to see if there is a medication order for abnormal glucose
levels.
4. Monitor and recheck in 2 hours. - answers :3
Which statement made by a patient of a 2-month-old infant requires further education?
1. I'll continue to use formula for the baby until he is a least a year old.
2. I'll make sure that i purchase iron-fortified formula.
3. I'll start feeding the baby cereal at 4 months.
4. I'm going to alternate formula with whole milk starting next month. - answers :4
The nurse is teaching a program on healthy nutrition at the senior community center.
Which points should be included in the program for older adults? (select all that apply.)
1. Avoid grapefruit and grapefruit juice, which impair drug absorption.
2. Increase the amount of carbohydrates for energy.
3. Take a multivitamin that includes vitamin d for bone health.
4. Cheese and eggs are good sources of protein.
5. Limit fluids to decrease the risk of edema. - answers :1, 3, 4
The nurse sees the nursing assistive personnel (nap) perform the following intervention
for a patient receiving continuous enteral feedings. Which action would require
immediate attention?
1. Fastening tube to the gown with new tape
2. Placing patient supine while giving a bath
3. Hanging a new container of enteral feeding
4. Ambulating patient with enteral feedings still infusing - answers :2
A patient is receiving total parenteral nutrition (tpn). What is the primary intervention the
nurse should follow to prevent a central line infection?
1. Institute isolation precautions
2. Clean the central line port through which the tpn is infusing with alcohol
3. Change the tpn tubing every 24 hours
4. Monitor glucose levels to watch and assess for glucose intolerance - answers :2
Which patients are at high risk for nutritional deficits? (select all that apply.)
1. The divorced computer programmer who eats precooked food from the local
restaurant
2. The middle-age female with celiac disease who does not follow her gluten-free diet
,3. The 45-year-old patient with type ii diabetes who monitors her carbohydrate intake
and exercises regularly
4. The 25-year-old patient with crohn's disease who follows a strict diet but does not
take vitamins or iron supplements
5. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and
protein levels are normal - answers :2, 4
What factors lead to impaired skin integrity and breakdown? - answers :immobility, poor
appetite, moisture/ sweating, shearing and friction, decreased loc, tissue perfusion, age,
infection
Methods a nurse uses to assess wounds/ infection/ healing - answers :appearance of
wounds, smell, discharge, color, swelling, measure of wound
Important nutrient for wound healing? How to test for it? - answers :protein, test for
albumin
Other names for pressure ulcer - answers :pressure ulcer, pressure sore, decubitus
ulcer and bedsore. They all mean impaired skin integrity r/t unrelieved prolonged
pressure
What is the difference in a partial thickness and full thickness wound? How do they
heal? - answers :partial: only partial loss of skin layers (the epidermis and superficial
dermal layers). Heals by regeneration
Full: total loss of the skin layer. Heals by forming new tissue (takes longer than partial to
heal which means there is a greater risk for infections in these kinds of wounds)
What are some complications of wound healing? - answers :hematoma- collection of
blood under tissue
Dehiscence- separation of wound layers
Hemorrhage- bleeding from a wound site
Evisceration- visceral organs profuse through the wound opening
The nurse is caring for a patient with pneumonia who has severe malnutrition. The
nurse recognizes that, because of the nutritional status, the patient is at increased risk
for:(select all that apply)
1. Heart disease
2. Sepsis
3. Pleural effusion
4. Cardiac arrhythmias
5. Diarrhea - answers :2, 3, 4
The nurse evaluates which laboratory values to assess a patents potential for wound
healing?
1. Fluid status
2. Potassium
, 3. Lipids
4. Nitrogen balance - answers :4
The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet
when she begins to choke. What is the priority nursing intervention?
1. Suction her mouth and through
2. Turn her on her side
3. Put on oxygen at 2-l nasal cannula
4. Stop feeding her and place on npo - answers :4
A patient who is receiving parenteral nutrition (pn) through a central veinous catheter
has an air embolus. What would the nurse do first?
1. Have the patient perform a valsalva maneuver
2. Clamp the iv tubing to prevent more air from entering the line
3. Have the patient take a deep breath and hold it
4. Notify the health care provider immediately - answers :1
A patient is receiving both parenteral (pn) and enteral nutrition (en). When would the
nurse collaborate with the hcp and request discontinuing pn?
1. When 25% of the patients nutritional needs are met by the tube feedings
2. When bowel sounds return
3. When the central line has been in for 10 days
4. When 75% of the patients nutritional needs are met by the tube feeding - answers :4
The nurse is educating the patient and his family about the parenteral nutrition. Which
aspect related to this form of nutrition would be appropriate to include? (select all that
apply)
1. The purpose of the fat emulsion in parenteral nutrition is to prevent deficiency in
essential fatty acids
2. We can give you perenteral nutrition through your peripheral iv line to prevent further
infection
3. The fat emulsion will help control hyperglycemia during periods of stress
4. The parenteral nutrition will help your wounds heal
5. Since we just started the pn, we will only infuse 50% of your daily needs for the next
6 hours - answers :1, 3, 4
What are the economic consequences of a pressure ulcer? - answers :hospitals do not
get reimbursed for a stage 3 or 4 pressure ulcer that occurs while hospitalized. Also a
pressure ulcer increases the duration of a patients stay which costs more money for
them
What are some implementations for pressure ulcers? - answers :topical skin care,
incontinence management, protect bony prominences, skin barriers for incontinence,
rotate patient, decrease the amount of pressure exerted over bony prominences
