,CM2 - EXAM 4 QUESTIONS WITH 100%
VERIFIED ANSWERS!!
The nurse is performing an initial assessment and notes that the client weighs
186.4 lb (84.7kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What
action by the nurse is appropriate?
A. Ask the client if the weight loss was intentional.
B. Determine if there are food allergies or intolerances. Had a 12% w
C. Perform a comprehensive nutritional assessment.
D. Perform a rapid bedside blood glucose test. Answer - A. Ask the client if the
weight loss was intentional
The nurse assesses a newly admitted client and documents a body mass index
(BMI) of 31.2. What does this value indicate to the nurse?
A. The client has a healthy weight.
B. The client is underweight.
C. The client is obese.
D. The client is overweight. Answer - C. The client is obese
A nurse is reviewing laboratory values for several clients. Which value indicates
a need for a nutritional assessment?
A. Client with an albumin of 3.5 g/dL
B. Client with a cholesterol of 142 mg/dL (3.7 mmol/L)
C. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L)
D. Client with a prealbumin of 28 mg/dl Answer - B. Client with a cholesterol of
142 (3.7 mol/L)
,A client is receiving bolus feedings through a small-bore nasoduodenal tube.
What action by the nurse is the priority?
A. Auscultate lung sounds after each feeding.
B. Weigh the client daily on the same scale.
C. Check tube placement every 8 hours.
D. Check tube placement before each feeding Answer - D. Check tube
placement before each feeding
A client receiving continuous tube feeding to provide total enteral nutrition
begins vommiting. What action by the nurse is most appropriate?
A. Administer an antiemetic.
B. Check the patient's gastric residual.
C. Hold the feeding unli the vomiting subsides.
D. Reduce the rate of the tube feeding by half. Answer - C. Hold the feeding
until the vomiting subsides
The nurse inserts a small-bore nasoduodenal tube for a client who is
undernourished. What priority nursing action is required prior to starting the
continuous tube feeding to confirm
correct tube placement?
A. Assess for carbon dioxide using capnometry.
B Perform pH testing of gastric fluid.
C. Auscultate over the epigastric area.
D. Request an x-ray before starting the feeding. Answer - D. Request an x-ray
before starting the feeding
, The nurse is caring for an older client receiving total enteral nutrition via a
small-bore nasoduodenal tube. For what priority complication would the nurse
assess?
A. Intermittent diarrhea
B. Cholecystitis
C. Aspiration pneumonia
D. Peptic ulcer disease Answer - C. Aspiration pneumonia
The nurse is managing care for a client receiving feeding through a gastrostomy
tube (G-tube). What assessment would the nurse perform?
A. Check the skin around the tube insertion site.
B. Weigh the client every shift with the same scale.
C. Draw blood to assess albumin every shift.
D. Irrigate the tube at least once a day. Answer - A. Check the skin around the
tube insertion site
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse
notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg,
skin is dry, and skin turgor is
poor. What action should the nurse perform next?
A. Assess the 24-hour intake and output.
B. Assess the client's oral cavity.
C. Prepare to hang a normal saline bolus.
D. Increase the infusion rate of the TPN. Answer - A. Assess the 24-hour intake
and output
A client who had minimally invasive bypass gastric surgery 2 days ago reports
new-onset of severe abdominal pain. What is the nurse's best action as this
time?
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