8/30/24, 10:59 Exam View - Chapter 55 - Ignatavicius: Medical-Surgical Nursing,
AM 10th Edi…
Chapter 55: Concepts of Care for Patients With Malnutrition: Undernutrition and Obesity Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). 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.
c. Perform a comprehensive nutritional assessment.
d. Perform a rapid bedside blood glucose test.
ANS: A
This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceed
to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other
findings, a blood glucose test may be warranted.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Nutrition, Assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. 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.
ANS: C
A BMI of over 30 indicates that the client is obese.
DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis
KEY: Nutrition, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. 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
ANS: B
A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priori
for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several
problems including dietary deficiencies, hemodilution, and bleeding.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Nutrition, Laboratory tests
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. 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.
ANS: D
For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than
every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already
occurred. Weighing the client is important to determine if nutritional goals are being met, but it is not the priority.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Undernutrition, Total enteral nutrition
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is
most appropriate?
a. Administer an antiemetic.
b. Check the patient’s gastric residual.
c. Hold the feeding until the vomiting subsides.
d. Reduce the rate of the tube feeding by half.
ANS: C
The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary healt
care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric
residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation
about:bl 1
, 8/30/24, 10:59 Exam View - Chapter 55 - Ignatavicius: Medical-Surgical Nursing,
AM 10th Edi…
KEY: Undernutrition, Total enteral nutrition
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
Copyright © 2021, Elsevier Inc. All rights reserved.
about:bl 2
AM 10th Edi…
Chapter 55: Concepts of Care for Patients With Malnutrition: Undernutrition and Obesity Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). 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.
c. Perform a comprehensive nutritional assessment.
d. Perform a rapid bedside blood glucose test.
ANS: A
This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceed
to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other
findings, a blood glucose test may be warranted.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Nutrition, Assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. 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.
ANS: C
A BMI of over 30 indicates that the client is obese.
DIF: Understanding TOP: Integrated Process: Nursing Process: Analysis
KEY: Nutrition, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. 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
ANS: B
A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priori
for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several
problems including dietary deficiencies, hemodilution, and bleeding.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Nutrition, Laboratory tests
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. 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.
ANS: D
For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than
every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already
occurred. Weighing the client is important to determine if nutritional goals are being met, but it is not the priority.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Undernutrition, Total enteral nutrition
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is
most appropriate?
a. Administer an antiemetic.
b. Check the patient’s gastric residual.
c. Hold the feeding until the vomiting subsides.
d. Reduce the rate of the tube feeding by half.
ANS: C
The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary healt
care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric
residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation
about:bl 1
, 8/30/24, 10:59 Exam View - Chapter 55 - Ignatavicius: Medical-Surgical Nursing,
AM 10th Edi…
KEY: Undernutrition, Total enteral nutrition
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
Copyright © 2021, Elsevier Inc. All rights reserved.
about:bl 2
