Physiological Adaptation Nutrition Rationales

Physiological Adaptation Nutrition 1. For a client receiving total parenteral nutrition (TPN), the nurse reviews the following lab values: Glucose = 72 mg/dL Chloride =98 mEq/L Sodium = 138 mEq/L Potassium = 3.0 mEq/L Based on this assessment, which nursing action is appropriate? a. Discontinue TPN administration. b. Notify physician and obtain order for potassium supplement. c. Administer IV glucose immediately. d. Check client vital signs immediately. The normal plasma potassium level is 3.5-5.5mEq/L. This clients potassium is low and needs replacement. Options #1, #3, and #4 do not address the problems. 2. Which nursing action is most appropriate for a 2-month-old infant with reflux? a. Hold the next feeding. b. Teach the mother CPR. c. Maintain normal feeding schedule. d. Elevate the head of the bed. An infant with reflux should be maintained in an upright position. The head of the bed should be raised at a 30degree angle. Option #1 may not be necessary, if positioning is effective. Option #2 is an action for the mother versus the infant. Option #3 is incorrect because the clients feedings should be changed to small volume, frequent feedings. 3. A client is taking metoclopramide hydrochloride (Reglan) orally for nausea secondary to chemotherapy. In reference to the timing of the medication, when would the nurse instruct the client to take the medication? a. With each meal b. Thirty minutes before meals c. One hour after each meal d. At the same time each day Since metaclopramide facilitates gastric emptying, it must be taken before meals. Options #1 and #3 do not promote optimum effects of the medication. Option #4 is incorrect because the time of administration should be changed to give with the clients meals. 4. Before breakfast, a 9-year-old child with juvenile diabetes (Type I) passed out on the living room floor after taking his morning insulin dose. The nurses best response is based on which concept? a. A child with a viral infection can have hypoglycemia, b. Children with diabetes may act out to get attention. c. Insulin shouldnt be taken until 30-60 minutes after breakfast. d. The morning dose caused hypoglycemia before the child ate. When children become distracted and fail to eat after a dose of insulin, hypoglycemia can easily occur. Option #1 is incorrect because viral infections result in hyperglycemia and there is no indication the child has an infection. Option #2 may be correct, but it would be a mistake to assume so in this situation. Option #3 is incorrect because insulin should be taken before meals. 5. A 3-month-old infant is scheduled for a barium swallow in the morning. Prior to the procedure, the most appropriate nursing action would be to: a. offer the infant only clear liquids. b. make the infant NPO for 3 hours. c. feed the infant regular formula. d. maintain NPO for 6 hours. An infant should be NPO 3 hours prior to the procedure. Options #1 and #3 are inappropriate. Option #4 is incorrect because it is not necessary for an infant to be NPO for 6 hours. 6. Which nursing action is most appropriate for a client receiving a tube feeding around the clock? a. Rinse the bag and change the formula every 4 hours. b. Rinse the bag and change the formula every shift. c. Change the bag and formula every shift. d. Rinse the bag and change the formula every 2 hours. Research indicates there is an increased growth of organisms after four hours. Options . #2 and #3 are inappropriate due to increased organism growth. Option #4 is not a necessary action to maintain asepsis. 7. A nurse is obtaining a health history from a mother of a child with failure to thrive. Which assessment would 1

provide the most pertinent data? a. Weight and height b. Urine output c. Type of feedings d. Mother-child interactions This provides the most pertinent data in assessing actual growth. Option #2 is inappropriate for this situation. Options #3 and #4 are important assessments but are not a priority to Option #1. 8. What instructions would a nurse give a diabetic client who has been vomiting for 24 hours and is concerned about blood glucose levels? a. Take only half of the regular insulin dose. b. Attempt to maintain a regular diabetic diet. c. Limit intake of sweets and sugar. d. Drink liquids as often as possible. Diabetic ketoacidosis is frequently associated with dehydration. Fluids should be encouraged. Option #1 is incorrect because a diabetic should alter the dose according to serial glucose checks. Option #2 is incorrect because the client is not tolerating PO foods. Option #3 is incorrect because sweets can be used as calories in this situation. 9. What type of foods would be best for an 8-year-old receiving chemotherapy? a. A diet high in nutrients b. Hot and spicy foods c. Small and frequent meals d. Foods on a regular schedule to promote a routine Offering small and frequent meals will help prevent nausea and enable the client to eat adequate amounts. Option #1 is important but is not a priority to Option #3. Option #2 may promote vomiting. Option #4 does not provide adjustments for the clients illness. 10. Which of the following would be the best plan for prevention of constipation during the first trimester of pregnancy? a. Take mineral oil every morning. b. Increase bulk and fiber in the diet. c. Take a mild laxative as needed. d. Decrease fluid intake. This will assist in preventing constipation. Options #1 and #3 are incorrect for the pregnant woman. Option #4 will lead to more constipation. 11. Which foods indicate the most appropriate breakfast choices for a young adult female client, 5'7" tall, weighing 257 pounds, who is seeking weight loss assistance? a. Applesauce, Cream of Wheat, toast b. Scrambled eggs and toast, one slice of bacon c. 1 glass of grapefruit juice d. Bagel with 2 ounces of cream cheese and a banana A breakfast with some substance wont leave her feeling hungry most of the morning. Options #2 and #4 have high fat content which is inappropriate for weight loss. Option #3 doesnt provide a balance of nutrients and may leave the client feeling very hungry before lunch. 12. While managing a clients nutritional status during the weaning from total parenteral nutrition (TPN), which nursing intervention should be most appropriate? a. Evaluate weight daily. b. Monitor I&O. c. Encourage client to eat a variety of foods. d. Maintain a calorie count. This is the best method of determining the clients nutritional status. Option #1 and #2 only indicate the clients hydration. Option #3 does not guarantee that this food will be eaten. 13. Which dietary requirements must be considered for an 8-year-old client with cystic fibrosis? a. High protein, high fat, and high calories b. High protein, low fat, and high calories c. Low protein, low fat, and low carbohydrates d. High protein, high fat, and low carbohydrates The impaired intestinal absorption of cystic fibrosis necessitates a diet higher in protein and calories. Fat is decreased because it may interfere with absorption of other nutrients. Options #1 and #4 contain high fat. Option 2

#3 is not adequate for this child. 14. A diabetic client, controlled with oral antihyperglycemic agents, questions the need for postoperative subcutaneous insulin injections. What is the most accurate explanation the nurse would give the client for the injections? a. Tissue injury after surgery decreases blood sugar. b. Anesthesia acts to increase glycogen stores. c. Being NPO inhibits normal blood sugar control. d. Surgery often leads to insulin dependency. The inability to control diabetes mellitus by diet and oral agents, coupled with surgically-induced metabolic changes, being NPO both prior to and after surgery, necessitates temporary control by insulin. Options #1, #2, and #4 are not true statements.

15. One hour after receiving 7 units of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be: a. notify the physician. b. call the lab for a blood glucose level. c. offer the client milk and crackers. d. administer glucagon. The onset of action for regular insulin is 30-60 minutes. The assessment indicates a problem with hypoglycemia. Foods such as milk and crackers should be given if the blood sugar level is around 40 to 60 mg/dL. If orange juice or simple sugar is given, it should be followed with a meal or protein intake. Option #1 is incorrect because action should be taken prior to notifying the physician. Option #2 delays the response to the problem. Option #4 is inappropriate for this client. 16. After a month of taking iron supplements, a client complains of constipation. Based on client tastes, the nurse adapts a diet plan to include: a. oatmeal, green beans, celery. b. strawberries, rice, mushrooms. c. grits, orange juice, cheddar cheese. d. pasta, buttermilk, banana. This option contains foods highest in fiber to assist in counteracting constipation (green vegetables and grains). Options #2, #3, and #4 do not have as high a fiber content. 17. Which foods would the nurse discourage the client from eating prior to a parathyroidectomy? a. Milk products. b. Green vegetables. c. Seafood. d. Poultry products. A low calcium diet is recommended preoperatively. Options #2, #3, and #4 would not be discouraged. 18. A school-aged child is being treated for Hepatitis A which was diagnosed two weeks ago. He plans to return to school this week with a physicians permit. The school nurse should plan for his return by: a. isolating him from the other children. b. talking with the physician about the reason for his return so soon. c. no specific health requirements are necessary. d. not allowing his participation in any sports. Type A Hepatitis is not infectious within a week or so after the onset of jaundice, and the child can return to school. Options #1 and #2 are not necessary. Option #4 depends on the childs energy level. 19. The nurse is preparing a teaching plan for feeding an infant postoperative repair of a cleft lip. In order to prevent complications, the nurse would teach the mother to: a. feed the infant with a newborn nipple while holding him in the recumbent position. b. clean the suture site with a cotton dipped swab soaked in Betadine. c. place the infant in prone position after feeding. d. feed the infant with a rubber-tipped syringe and bubble frequently. The rubber tip can be placed in from the side of the mouth to avoid the operative area and to prevent sucking on the tubing. Infants with cleft lip swallow excessive amounts of air so they require frequent bubbling. Option #1 is unsafe due to aspiration. Option #2 is incorrect. Option #3 is incorrect because the site is cleansed with saline or hydrogen peroxide. 3

20. Which assessment indicative of hypoglycemia would be most important to report to the next shift for a client who received 6 units of regular insulin 3 hours ago? a. Kussmauls respirations and diaphoresis. b. Anorexia and lethargic. c. Diaphoresis and trembling. d. Headache and polyuria. Regular insulin peaks in 2-4 hours. These are signs of hypoglycemia which may occur. Option #1 is incorrect because Kussmaul's respirations are signs of hyperglycemia. Options #2 and #4 are not indicative of hypoglycemia. 21. A teenager with newly diagnosed diabetes is being discharged. Which client statement indicates an understanding of insulin? a. "The peak action for Humulin N insulin is 5-10 hours." b. "The peak action for Semilente insulin is 2-3 hours." c. "Ultra Lente insulin is effective for 8-12 hours." d. "The onset action for Humulin R insulin is 1-1-1/2 hours." Humulin N, an intermediate acting insulin, has a peak action of 5-12 hours. Option #2 is incorrect because Semilente, a rapid acting insulin, peaks between 8-10 hours. Option #3 is incorrect because Ultra Lente, a longacting insulin, is effective for 36+ hours. Option #4 is incorrect because the onset of action for regular insulin is between 1/2 to1 hour. 22. A newborn infant is given vitamin K (AquaMephyton) IM. Which concept is this treatment based on? a. The infant cannot tolerate foods that are high in vitamin K. b. There is potential bleeding because of immature liver and insufficient vitamin K. c. Infants do not have an adequate supply of vitamin K at birth and require a supplement. d. The normal intestinal flora required to synthesize vitamin K is not present. The synthesis and utilization of vitamin K is dependent on normal intestinal flora. The newborn is at risk of bleeding problems until normal flora develops. Option #1 is incorrect because the infant does not have to take in high vitamin K foods. Options #2 and #3 are incorrect because the problem is not with the supply but the ability of the body to utilize it. 23. A geriatric client is admitted with a left-sided paralysis. Which data would offer the nurse the most useful information regarding dietary intake? The clients: a. favorite foods. b. ability to chew and swallow. c. normal bowel schedule. d. routine meal times before admission. The ability of the client to chew and swallow will be the basis of planning. Options #1 and #4 wont make any difference if he cannot chew. Option #3 would be important in avoiding constipation. 24. A 3-year-old is admitted with nausea and vomiting. The nurse would offer which foods for initial PO intake? a. Ice cream b. Apple juice c. Orange juice d. Pudding Clear liquids should be offered first. As child tolerates these fluids, then full liquids may be offered. Options #1, #3, and #4 are all part of a full liquid diet. 25. The client with peptic ulcer disease wants to know why he is taking ranitidine (Zantac) at bedtime. Which response is best? a. "When the physician ordered this medication, he said to give it at bedtime." b. "Taking Zantac at bedtime suppresses acid production through the night." c. "The foods taken during the day may interfere with the effectiveness of the medication." d. "Antacids interfere with the absorption of other drugs. Therefore, the medication is administered at bedtime." Bedtime administration suppresses nocturnal acid production. Option #1 may be correct, but Option #2 is a more complete answer. Option #3 is incorrect. Although foods sometime interfere with the effectiveness of some medications, this is not the rationale for giving Zantac at bedtime. Option #4 is incorrect because Zantac is an H^ antagonist not an antacid.

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26. An adult client has Humulin R insulin ordered for 7:30 am. The nurse notes the client's blood glucose level is 68 mg/L and the client is nauseated. What action should the nurse take? a. Immediately give the client orange juice to drink. b. Administer the insulin on time. c. Withhold the insulin and notify the physician. d. Return the breakfast try to the kitchen. The blood glucose is within normal limits (60-110 mg/dL). Considering that the client is nauseated, breakfast will not be tolerated. Giving the insulin at this time may produce severe hypoglycemia. Option #1 may cause vomiting. Option #2 ignores the client. Option #4 does not address the client's problem. 27. Why would a nurse suggest a client with a hiatal hernia not eat or drink anything prior to going to bed? a. The client is less likely to awaken during the night with heartburn if the stomach is empty. b. Early morning vomiting will be less of a problem if the stomach is empty. c. Drinking or eating prior to lying down causes decreased respirations due to increased pressure on the lung. d. The client may develop fluid overload if fluids are taken just prior to going to bed. The full stomach is more likely to slide (reflux) through the hernia causing regurgitation and heartburn. Option #2 is incorrect because clients tend to have problems with vomiting 30-45 minutes after a meal. They need to remain upright 30-45 minutes after meals to prevent problems with aspiration from vomiting. Options #3 and #4 are incorrect because vomiting, decreased respirations, and fluid overload are not related to hiatal hernia. 28. At a health screening clinic, an adult male client's total plasma cholesterol level is reported to be 200 mg/dL. Based on this assessment, which nursing action is most appropriate? a. Refer the client to a physician for appropriate medication. b. Ask the client to lay down immediately. c. Encourage the client to follow a low-fat diet. d. Recheck the cholesterol level in two years. The total cholesterol level for an adult male should be under 200 mg/dL. Higher levels require a low-fat diet. Levels higher than 250 mg/dL may require medication, if diet therapy is not effective. Option #1 is not necessary prior to working on diet. Option #2. Option #4 is incorrect because blood levels should be checked sooner than 2 years. 29. An 82-year-old client is diagnosed with a vitamin K deficiency due to dietary malabsorption. Which nursing intervention is most appropriate for this client? a. Encourage the client to remain in bed to decrease bleeding potential. b. Carefully check the clients arm after taking blood pressure. c. Increase clients dietary intake of fruits and fiber. d. Observe client carefully for signs of angina or cardiac dysrhythmia. Due to the potential for bleeding, the clients arm should be observed for bruising after taking a blood pressure reading. Option #1 is incorrect because remaining in bed does not decrease the potential for bleeding. Option #3 does not affect absorption of vitamin K. Option #4 is not appropriate for vitamin K deficiency. 30. A client is scheduled for a cholangiogram. Prior to the administration ofmeglumine diatrizoate (Gastrografin), the nurse should: a. identify the client before administering the medication. b. administer the medication 2 hours before the upper GI. c. administer an enema after giving the medication. d. instruct the client to take medication slowly with water. Appropriate identification of client is the first nursing priority after the order is verified (5Rights of medication administration). Options #2, #3, and #4 are incorrect. 31. A client with a colostomy wants to know if other people will be able to smell him. The best response by the nurse would be: a. "Keep your bag clean to reduce this possibility." b. "You can eat onions, beans and cucumbers." c. "You could eat oranges, yogurt and drink buttermilk." d. "You can take a nonprescription medicine that controls smell." Cleanliness is known to control odor. Option #2 causes gas production. Option #3 is ineffective. Option #4 is incorrect because the client should check with his physician before taking any over-the-counter drugs. 32. A client is placed on cephalexin monohydrate (K-eflex) prophylactically after surgery. Which foods would the nurse encourage? 5

a. Bran cereals and fruits b. Egg white and lean meats c. Yogurt and acidophilus milk d. Fish and poultry meats These foods will help maintain normal intestinal flora. Options #1, #2, and #4 are not necessary to encourage. 33. In planning dietary instructions for the client with diverticular disease without symptoms ofdiverticu litis. the nurse would caution the client to avoid which foods? a. Fresh tomatoes b. Fresh carrots c. Fresh lettuce d. Whole-wheat bread Fresh tomatoes should be avoided because they contain indigestible roughage and seeds that may block the neck of a diverticulum. Options #2 and #3 are incorrect because fresh carrots and lettuce are encouraged for a high- fiber content to add bulk to stools. Option #4 is incorrect because the client with diverticulosis is encouraged to eat a diet high in cellulose and hemicellulose types of fiber found in wheat bran and whole-wheat bread. 34. Which instructions should be given to an adult client in preparation for a plasma cholesterol screening? a. Eat a vegetarian diet for one week before the test. b. Limit alcohol intake to two glasses of wine the day before the test. c. Abstain from dairy products for 48 hours before the test. d. Only sips of water should be taken for 12 hours before the test. Only sips of water are permitted for 12 hours before plasma cholesterol screening for accurate results. Options #1 and #3 are incorrect because a normal diet should be eaten the week before the test. Option #2 is incorrect because alcohol intake will interfere with test results. 35. What would be the priority of care for a client who has a blood sugar of 200 at 7:00 AM? a. Increase the PM dose of NPH insulin. b. Increase the AM dose of regular insulin. c. Wake the client up at 3:00 AM and evaluate the blood sugar. d. Decrease the PM dose of NPH insulin. It is important to know what the 3:00 AM blood sugar is to determine if the hyperglyce-mia is from the somoygi effect. Options #1 and #4 will be adjusted after knowing if the AM blood sugar is the accurate reading or a rebound response to a low blood sugar at 3:00 AM. Option #2 is incorrect. 36. In providing nutritional teaching to a new breastfeeding mother, the nurse may advise the client to increase her caloric intake by how many calories? a. 200 b. 300 c. 400 d. 500 Milk production requires an increase of 500 calories per day. Options #1, #2, and #3 contain too few calories to support breastfeeding. 37. In teaching a newly diagnosed diabetic client how to give insulin injections, the nurse would; a. demonstrate how to give an insulin injection on herself. b. provide the client with a pamphlet on how to give injections. c. provide the client with a doll to practice her injection technique. d. let the client practice giving the injection to the nurse. A client should be given a doll to practice injection technique. Options #1 and #2 may be appropriate, but Option #3 provides the best teaching method. Option #4 is not recommended. 38. Which statement made by the family indicates a correct understanding of the appropriate diet for a child with celiac disease? a. "My child's diet should include raw vegetables, fruits, and crackers." b. "My child's diet should include high carbohydrates, high calories, and high proteins." c. "The only restriction in my child's diet should be breads and cereals." d. "My child's diet should include high calories, high protein, and restrict foods containing rye, oats, wheat and barley." Celiac disease is characterized by an intolerance of gluten. Therefore, foods containing rye, oats, wheat, and barley should be restricted from the clients diet. Options #1, #2, and #3 do not reflect appropriate dietary needs for this client. 6

39. During the first 24 hours after total parenteral nutrition (TPN) therapy is started, the nurse should: a. monitor vital signs every two hours. b. determine urinalysis results. c. evaluate blood glucose levels. d. compare weight with previous weight record. Total parenteral nutrition (TPN), or hyper-alimentation, has a high glucose content. Therefore, it is important to monitor glucose levels. Options #1 and #2 are inappropriate. Option #4 is appropriate, but not a priority. 40. To evaluate the progress of the client trying to lose weight, which information would the nurse use? a. Listing of food preferences b. History of weight gain/loss c. Familial history of obesity d. Weekly log of weight gain/loss The weekly log of weight gain/loss would indicate progress of client in losing weight. Options #1, #2, and #3 are important for history taking and planning. 41. Which food would the nurse encourage a low income client to eat to satisfy essential protein needs? a. Legumes b. Red meat c. Seafood d. Cheese Legumes are an economical source rich in protein. Options #2, #3, and #4 are high in protein but more expensive to purchase. 42. Which assessment would be indicative of hypocalcemia? a. Constipation b. Depressed reflexes c. Decreased muscle strength d. Positive Trousseaus sign A positive Trousseaus sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia. Options #1, #2, and #3 are symptoms associated with hypercalcemia.

43. Which of the following dietary modifications should the nurse suggest to a client receiving peritoneal dialysis? a. Limit the amount of protein in the diet. b. Eat high fiber foods to help prevent constipation. c. Encourage dairy products to increase phosphorus. d. Recommend beans and cheese to assist indigestion. Option #2 is correct. Constipation should be avoided with peritoneal dialysis as it will contribute to fullness and discomfort with exchanges. Option #1 is incorrect as protein is lost with peritoneal dialysis and needs to be replaced in the diet. (This is untrue with hemodialysis.) Option #3 is not needed with these clients. Option #4 is incorrect as these foods can lead to gas and constipation which would increase discomfort with exchanges. 44. Which foods would the nurse include in the diet for a client who has high cholesterol and triglyceride levels? a. Avocados, processed meats b. Red meat, eggs c. Whole grain cereals, pasta d. Olives, shell fish, whole milk Whole grain cereals have little or no fat content. Options #1, #2, and #4 have high fat content. 45. In working with an overweight adolescent with hypertension, the most helpful suggestion the nurse could make regarding long-term health promotion and maintenance would be to: a. avoid participating in organized sports. b. join an adolescent weight reduction support group. c. limit socialization with non-overweight friends. d. adhere to a 1000 calorie, low-fat diet. This is an excellent means of obtaining information and support while helping the client. Option # 1 is incorrect because properly supervised physical activity is desirable, not to be avoided. Option #3 is incorrect because peer relationships are important, not to be avoided. Option #4 is not enough calories for an adolescent, and a diet too low in calories is hard to comply with and may set the adolescent up for failure. 7

46. Which statement made by a mother of a child with celiac disease indicates an understanding of the appropriate diet? a. "I will need to provide low protein and low fat meals to increase food absorption." b. "My child will need an increase in high fiber foods to prevent problems of constipation." c. "I understand that wheat and oats are not included in a gluten-free diet." d. "A high protein diet with easily digested carbohydrates will increase nutrition." Celiac Disease is an inborn error in metabolism of rye, wheat, and oat products. Primary dietary management is a gluten-free diet. Options #1, #2, and #4 are not correct statements regarding a gluten-free diet. 47. Which comment would indicate that a pregnant woman understands the recommended dietary caloric increase for pregnancy? a. "I will need to double my calorie intake since I am now eating for two of us." b. "I can add an additional 500 calories by drinking milk shakes." c. "I need to add 300 calories by increasing intake of basic four food groups." d. "I really need to watch my calorie intake so I will not gain too much weight." It is recommended to increase intake of a healthy diet by 300 calories. This is for fetal growth, maternal tissues, and the placenta. Option #1 is a common misconception. Option #2 is incorrect because 500 calories are too many calories, and a milkshake is not a good food source because of fat content. Option #4 is not safe for the pregnant client. 48. To prevent the spread of Hepatitis A, the most effective measure the nurse should teach the client and close associates would be to: a. wash their hands every time they go to the bathroom. b. wash all dishes in a dishwasher. c. teach drug addicts never to share their used needles. d. always use condoms during sexual intercourse. Type A Hepatitis is spread by oral-fecal route so it is important to teach effective hand-washing every time the client uses the bathroom or has genital-rectal contact. Options #2, #3, and #4 are not true for Hepatitis A. 49. The nurse may suggest the client take prenatal vitamins daily with: a. orange juice at bedtime. b. breakfast. c. milk at lunch. d. water at dinner. Taking the vitamin with something acid increases the absorption of iron, and taking them with food and at bedtime decreases the possibility of nausea as the client will be asleep. Option #2 is not a priority to Option #1. Options #3 and #4 are incorrect because milk and water are less effective fluids. 50. When teaching a newly diagnosed diabetic about regulating her diabetes at home, the nurse would include which instructions? a. Limit vigorous exercise. b. Eliminate sugar from the diet. c. Test blood sugar at regular intervals. d. Limit carbohydrates in the diet. Testing blood sugar levels several times each day gives the client information about the regulation of insulin and blood sugar. This information would be important in assessing the control of this disease process. Option #1is incorrect because regular exercise should be encouraged. Option #2 is correct for a diabetic. However, Option #3 is a higher priority. Option #4 is not correct for the diabetic diet. 51. A client has a nasogastric tube in place after extensive abdominal surgery. He complains of nausea. His abdomen is distended, and there are no bowel sounds. The first nursing action would be to: a. administer the PRN pain medication and antiemetic. b. irrigate the nasogastric tube with normal saline. c. re-anchor a new nasogastric tube. check the placement d. and patency of the nasogastric tube by auscultation. The first assessment in determining problems with nasogastric tubes is to determine tube placement and patency. Option #1 may be implemented after the placement and patency of the tube are determined. Option #2 would be completed only after Option #4 was completed. Option #3 is inappropriate without further assessment. 52. A good menu selection for a client with a gallbladder disturbance would include: a. skimmed milk, banana, broiled fish, lettuce salad. b. skimmed milk, bran cereal, apple, fried eggs. 8

c. tea, carrots, bran muffins, and pork chops. d. tea, broccoli, broiled fish, and pie. The diet would be low in fat, spices, condiments, and coffee. Options #2, #3, and #4 are incorrect because cooked vegetables, raw vegetables (except lettuce), and eggs are usually not tolerated. All fried foods and pastries should be avoided. 53. Which foods would reflect appropriate selection for a client on a low residue diet? a. Milk, green beans, whole wheat bread b. Creamed chicken soup, broccoli, pudding c. Baked chicken, buttered rice, plain gelatin d. Cabbage salad, fried chicken, applesauce A low residue diet will leave a relatively small amount of residue or indigestible material in the colon. All meats, fish and poultry must be broiled or baked. Options #1, #2, and #4 contain a high residue food. 54. Which information should the nurse recognize as being the most pertinent to the diagnosis of cholecystitis? a. Flatulence b. Nausea and vomiting c. Right upper abdominal pain d. Dyspepsia The most pertinent to the diagnosis of cholecystitis is the pain in the right upper abdominal quadrant. Options #1, #2, and #4 may indicate other gastrointestinal problems. 55. Which statement made by the client indicates a correct understanding of cholecystectomy? a. "After this surgery, I’ll be able to eat anything." b. "I'll be able to drink coffee and colas again." c. "If I start having a fever, I need to call my physician." d. "I won't have indigestion or heartburn anymore." A fever may indicate an infection and should be reported to the physician. Options #1, #2, and #4 are incorrect because the client may continue to have trouble with certain foods. Indigestion and heartburn may occur for an indefinite period of time after surgery. 56. The nurse should be alert to the development of which of these symptoms as the major complication of peritoneal dialysis? a. Decreased urine output b. Elevated creatinine c. Cloudy return of dialysate d. Weight gain Option #3 is correct. This is an indication of the development of peritonitis. Option #1 is incorrect as the client with chronic renal failure may have no urine output normally. Option #2 is incorrect as a client with chronic renal failure will have an elevated creatinine. Option #4 is incorrect. Although weight gain may indicate that fluid retention is occurring, peritonitis is a more serious complication associated with this procedure. 57. Which outcome best evaluates the effectiveness of health promotion regarding a self-care deficit in relation to feeding? a. The client eats at least one half of all meals and drinks a minimum of 2000 ml/day. b. The clients dentures have been replaced, and he is able to chew. c. The client will eat without verbalizing suspicions when one particular nurse sits with him. d. The client appears to have increased energy to complete grooming activities. This is a concrete measure of the client's eating patterns which indicates adequate intake of a well-balanced diet. Option #2 may not present a well-balanced diet. Option #3 indicates that the client is still experiencing distorted thinking about the foods to eat. Option #4 may not be an accurate measure of adequate nutrition. 58. When would the nurse anticipate the client with a gastric ulcer to have pain? a. Two to three hours after a meal b. At night c. Relieved by ingestion of food d. One half to one hour after a meal Pain related to a gastric ulcer occurs about 1/2 to 1 hour after a meal, rarely at night, and is not helped by ingestion of food. Options #1, #2, and #3 are features of a duodenal ulcer. 59. Which nursing observations would indicate the client has developed complications of cholecystitis? a. Nausea 9

b. Indigestion and frequent belching c. Jaundice d. Right upper abdominal pain Jaundice indicates possible stone in the bile duct causing obstruction. Options #1, #2, and #4 are signs and symptoms of cholecystitis and do not necessarily indicate a complication. 60. Which statement made by a client with Hepatitis A indicates a need for further teaching? a. "I have been very careful to wash my hands after I go to the bathroom." b. "I have had to take a lot of Tylenol this week for this sinus infection I have." c. "I have been very careful not to handle my child's toys or eating utensils." d. "My husband has been preparing all of the meals since I've been sick." The client should be cautioned about taking any drugs not approved by the health care provider, as they may become dangerous because of the livers inability to detoxify and excrete them. Options #1, #3, and #4 are correct statements. Since Hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing technique and avoiding contact with items that will be placed in others mouths.

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