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Nutrition and tissue integrity NCLEX questions with complete Rationale solutions| complete Questions and 100% correct answers
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Nutrition and tissue integrity NCLEX questions with complete Rationale solutions| complete Questions and 100% correct answers

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  • April 29, 2024
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  • 2023/2024
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Terms in this set (67)
The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III
pressure ulcer on the sacral area. The patient’ s daughter will be dressing the wound at home. Which steps
should the nurse include in the teaching plan? ( Select all that apply .)
a. Applying a dry sterile dressing
b. Cleansing the wound
c. Managing pain
d. Using cold water in the bath
e. Hand washing
B, C, E
Administering pain medications will ensure that the patient is comfortable prior to a dressing change. Hands should be washed before and after
performing a dressing change. The nurse should show the daughter how to cleanse the wound and then apply the sterile. The order calls for a wet-to-dry
normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.
The nurse in the skilled nursing facility is very busy and unable to answer all the call lights. Which tasks related
to skin care can the nurse delegate to the nursing assistant? ( Select all that apply .)
a. Assessing a patient complaining of an itching rash
b. Assisting the client with frequent turning to prevent pressure ulcers
c. Covering the client who complains of being cold with more blankets
d. Placing a sterile gauze pad over broken skin to contain drainage
e. Applying over-the-counter lotions to skin that is not broken
B, C, D, E
All the above options can be delegated to an unlicensed assistive personnel employee except assessing a patient complaining of an itching rash.
Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary . The nurse needs to investigate a new rash for
the possibility of an allergic reaction.
To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations
should the nurse provide? ( Select all that apply .)
a. Drink plenty of water .
b. Eat plenty of foods high in vitamin K.
c. Apply sunscreen 30 minutes prior to exposure.
d. Wear sunglasses.
e. Consume fish oil and vitamin E.
C, D, E
Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not
prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however ,
vitamin K can cause the blood to clot and is not in a recommendation for the prevention of melanoma.
A nurse is instructing a nursing assistant on how to prevent pressure ulcers for frail elderly clients. The action by
the nursing assistant indicates understanding of the instructions? ( Select all that apply .)
a. Maintains a cooler environment when bathing
b. Bathes and dries the skin vigorously to stimulate circulation
c. Of fers nutritional supplements and frequent snacks
d. Keeps the head of the bed elevated 45 degrees
e. Turns the patient at least every 2 hours
C, E
The patient should be turned at least every 2 hours because permanent damage to the tissues can occur at pressure points in 2 hours or less. If skin
assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently . Protein-calorie
malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin.
Elevation of the head of the bed more than 30 degrees and overstimulation of the skin may stimulate, if not actually encourage, dermal decline. Older
adults are more prone to hypothermia if bathed in a cooler environment. The nurse is assessing a group of patients to determine their risk of vitamin D deficiency . Which of the following
patients has the highest risk for vitamin D deficiency?
a. A Hispanic female who has a BMI of 24.1
b. An African-American female who is breastfeeding
c. An Asian female diagnosed with hypoglycemia
d. A Caucasian female who is 39 weeks gestation
b. An African-American female who is breastfeeding
Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of
breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D
deficiency; however , diabetes increases the risk for vitamin D deficiency . There is no known risk of vitamin D deficiency in normal-weight females of
Hispanic heritage; however , obesity is a risk factor .
Appropriate approaches used by the long-term care nurse to provide education for a 73 year old who has just
been diagnosed with diabetes include which of the following? ( Select all that apply .)
a. Encourage the patient’ s family to participate in teaching sessions.
b. Avoid discussion of the patient’ s favorite foods.
c. Remind the patient that a lot of damage has already occurred.
d. Schedule a visit by another resident who is diabetic.
e. Demonstrate food choices using food photographs.
f. Ask the patient about past experiences with lifestyle changes.
A, D, E, F
Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences.
Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already
done will indicate that the changes are not worth the ef fort.
A nurse in a home setting is assessing a 79-year-old male patient’ s risk for malnutrition. The nurse suspects
malnutrition when reviewing which laboratory results? ( Select all that apply .)
a. Waist-to-hip ratio of 1.0
b. Hematocrit level of 50%
c. Weight loss of 6% since last month’ s visit
d. Hemoglobin level of 8.2 g/dL
e. Body mass index (BMI) of 17
f. Prealbumin level of 16 mg/dL
B, C, D
A BMI of 18.5-24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and
the expected hemoglobin level for a man is 14-18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15-36
mg/dL. A hematocrit level of 50% is within normal limits.
1. The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the
patient for which of the following assessment findings? (Select all that apply .) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea
1. Answer: 2, 3, 4. Patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, skin breakdown,
sepsis, or hemorrhage during hospitalization.
2. The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition?
(Select all that apply .) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN
Answer: 1, 5. When a client is malnourished, he or she is in a state of negative nitrogen balance—meaning, the body is experiencing protein loss and
requires more protein to maintain healing. Therefore, total protein will indicate the amount of muscle breakdown and protein loss. Albumin is a serum
binding protein, and lower levels can be an indicator of malnutrition, but it is really more indicative of inflammation or kidney and liver disease. As a result,
this is not the gold standard for diagnosing malnutrition. BUN is also an indicator because urea is the end product of protein metabolism, and when a
patient is not getting enough protein, you will see a decreased BUN. 3. The nurse is caring for a client 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 throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her
3. Answer: 4. Stop feeding and then place patient on side. If choking persists, suction airway . Notify health care provider . Keep patient NPO
4. A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus.
What should be the nurse’ s priority action? 1. Have the patient turn on the left side and perform a V alsalva maneuver . 2. Clamp the intravenous (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
4. Answer: 1. Turn the patient on his or her left side to prevent air from entering the left side of the heart. Then have the patient perform a V alsalva
maneuver (holding the breath and “bearing down”). 5. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health
care provider and request a discontinuation of parenteral nutrition?
1. When 25% of the patient's 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 patient's nutritional needs are met by the tube feedings
5. Answer: 4. When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy .
6. A client is receiving an enteral feeding at 65 mL/hr . The gastric residual volume in 4 hours was 125 mL. What is
the priority nursing intervention? 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees.
3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider .
6. Answer: 3. Delayed gastric emptying is a concern if 250 mL or more remains in a patient’ s stomach on two consecutive assessments (1 hour apart) or
if a single GR V measurement exceeds 500 mL. Therefore the best action is to continue the tube feedings at this time. 7. Which action can a nurse delegate to assistive personnel (AP)? 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client’ s tolerance of the enteral feeding
7. Answer: 1. The skills of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to AP. The nurse needs to administer
enteral feeding because of the risk of aspiration. The nurse is responsible for teaching the client and evaluating the tolerance to the enteral feeding.
8. Which statement made by the parents of a 2-month-old infant requires further education by the nurse? 1. “I’ll continue to use formula for the baby until he is at 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.”
8. Answer: 4. Infants should not have regular cow’ s milk during the first year of life. It is too concentrated for the infant’ s kidneys to manage. There is also
an increased risk for developing milk-product allergies.

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