NURS (FUNDAMENTAL): Ch 35 NCLEX Nutrition – Q&A
A nurse is feeding an elderly patient who has dementia. Which intervention
should the nurse perform to facilitate this process?
a) Stroke the underside of the patient's chin to promote swallowing.
b) Serve meals in different places and at different times.
c) Offer a whole tray of various foods to choose from.
d) Avoid between-meal snacks to ensure hunger at mealtime. ✔️Ans - a)
Stroke the underside of the patient's chin to promote swallowing.
To feed a patient with dementia, the nurse should stroke the underside of
the patient's chin to promote swallowing, serve meals in the same place
and at the same time, provide one food item at a time since a whole tray
may be overwhelming, and provide between-meal snacks that are easy to
consume using the hands.
A 56-year-old male patient who has COPD is refusing to eat. Which
intervention would be most helpful in stimulating his appetite?
a) Administering pain medication after meals.
b) Encouraging food from home when possible.
c) Scheduling his respiratory therapy before each meal.
d) Reinforcing the importance of his eating exactly what is delivered to him.
✔️Ans - b) Encouraging food from home when possible.
Food from home that the patient enjoys may stimulate him to eat. Pain
medication should be given before meals, respiratory therapy should be
scheduled after meals, and telling the patient what he must eat is no
guarantee that he will comply.
A nurse is feeding a patient who is experiencing dysphagia. Which nursing
intervention would the nurse initiate for this patient?
a) Feed the patient solids first and then liquids last.
b) Place the head of the bed at a 30-degree angle during feeding.
c) Puree all foods to a liquid consistency.
,d) Provide a thirty-minute rest period prior to mealtime. ✔️Ans - d)
Provide a thirty-minute rest period prior to mealtime.
When feeding a patient who has dysphagia, the nurse should provide a 30-
minute rest period prior to mealtime to promote swallowing; alternate
solids and liquids when feeding the patient; sit the patient upright or, if on
bedrest, elevate the head of the bed at a 90-degree angle; and initiate a
nutrition consult for diet modification and food size and/or consistency.
A nurse is feeding a patient who states that she is feeling nauseated and
can't eat what is being offered. What would be the most appropriate initial
action of the nurse in this situation?
a) Remove the tray from the room.
b) Administer an antiemetic and encourage the patient to take small
amounts.
c) Explore with the patient why she does not want to eat her food.
e) Offer high-calorie snacks such as pudding and ice cream. ✔️Ans - a)
Remove the tray from the room.
The first action of the nurse when a patient has nausea is to remove the
tray from the room. The nurse may then offer small amounts of foods and
liquids such as crackers or ginger ale. The nurse may also administer a
prescribed antiemetic and try small amounts of food when it takes effect.
A 62-year-old male patient has been admitted to the alcoholic referral unit
in the local hospital. Based on an understanding of the effects of alcohol on
the GI tract, which is a priority concern related to nutrition?
a) Vitamin B malnutrition
b) Obesity
c) Dehydration
d) Vitamin C deficiency ✔️Ans - a Vitamin B malnutrition
The need for B vitamins is increased in alcoholics because these nutrients
are used to metabolize alcohol, thus depleting their supply. Alcohol abuse
specifically affects the B vitamins. Obesity, dehydration, and vitamin C
deficiency may be present, but these are not directly related to the effect of
alcohol on the GI tract.
, A nurse is caring for a newly placed gastrostomy tube of a postoperative
patient. Which nursing action is performed correctly?
a) The nurse dips a cotton-tipped applicator into sterile saline solution and
gently cleans around the insertion site.
b) The nurse wets a washcloth and washes the area around the tube with
soap and water.
c) The nurse adjusts the external disk every 3 hours to avoid crusting
around the tube.
d) The nurse tapes a gauze dressing over the site after cleansing it. ✔️Ans
- a) The nurse dips a cotton-tipped applicator into sterile saline solution
and gently cleans around the insertion site.
When caring for a new gastrostomy tube, the nurse would use a cotton-
tipped applicator dipped in sterile saline to gently cleanse the area,
removing any crust or drainage. The nurse would not use a washcloth with
soap and water on a new gastrostomy tube, but may use this method if the
site is healed. Also, once the sutures are removed, the nurse should rotate
the external bumper 90 degrees once a day. The nurse should leave the site
open to air unless there is drainage. If there is drainage, one thickness of
precut gauze should be placed under the external bumper and changed as
needed to keep the area dry.
A nurse is assessing a patient who has been NPO (nothing by mouth) prior
to abdominal surgery. The patient is ordered a clear liquid diet for
breakfast, to advance to a house diet as tolerated. Which assessments
would indicate to the nurse that the patient's diet should not be advanced?
a) The patient consumed 75% of the liquids on her breakfast tray.
b) The patient tells you she is hungry.
c) The patient's abdomen is soft, nondistended, with bowel sounds.
d) The patient reports fullness and diarrhea after breakfast. ✔️Ans - d)
The patient reports fullness and diarrhea after breakfast.
Tolerance of diet can be assessed by the following: absence of nausea,
vomiting, and diarrhea; absence of feelings of fullness; absence of
abdominal pain and distention; feelings of hunger; and the ability to
consume at least 50% to 75% of the food on the meal tray.
A nurse is feeding an elderly patient who has dementia. Which intervention
should the nurse perform to facilitate this process?
a) Stroke the underside of the patient's chin to promote swallowing.
b) Serve meals in different places and at different times.
c) Offer a whole tray of various foods to choose from.
d) Avoid between-meal snacks to ensure hunger at mealtime. ✔️Ans - a)
Stroke the underside of the patient's chin to promote swallowing.
To feed a patient with dementia, the nurse should stroke the underside of
the patient's chin to promote swallowing, serve meals in the same place
and at the same time, provide one food item at a time since a whole tray
may be overwhelming, and provide between-meal snacks that are easy to
consume using the hands.
A 56-year-old male patient who has COPD is refusing to eat. Which
intervention would be most helpful in stimulating his appetite?
a) Administering pain medication after meals.
b) Encouraging food from home when possible.
c) Scheduling his respiratory therapy before each meal.
d) Reinforcing the importance of his eating exactly what is delivered to him.
✔️Ans - b) Encouraging food from home when possible.
Food from home that the patient enjoys may stimulate him to eat. Pain
medication should be given before meals, respiratory therapy should be
scheduled after meals, and telling the patient what he must eat is no
guarantee that he will comply.
A nurse is feeding a patient who is experiencing dysphagia. Which nursing
intervention would the nurse initiate for this patient?
a) Feed the patient solids first and then liquids last.
b) Place the head of the bed at a 30-degree angle during feeding.
c) Puree all foods to a liquid consistency.
,d) Provide a thirty-minute rest period prior to mealtime. ✔️Ans - d)
Provide a thirty-minute rest period prior to mealtime.
When feeding a patient who has dysphagia, the nurse should provide a 30-
minute rest period prior to mealtime to promote swallowing; alternate
solids and liquids when feeding the patient; sit the patient upright or, if on
bedrest, elevate the head of the bed at a 90-degree angle; and initiate a
nutrition consult for diet modification and food size and/or consistency.
A nurse is feeding a patient who states that she is feeling nauseated and
can't eat what is being offered. What would be the most appropriate initial
action of the nurse in this situation?
a) Remove the tray from the room.
b) Administer an antiemetic and encourage the patient to take small
amounts.
c) Explore with the patient why she does not want to eat her food.
e) Offer high-calorie snacks such as pudding and ice cream. ✔️Ans - a)
Remove the tray from the room.
The first action of the nurse when a patient has nausea is to remove the
tray from the room. The nurse may then offer small amounts of foods and
liquids such as crackers or ginger ale. The nurse may also administer a
prescribed antiemetic and try small amounts of food when it takes effect.
A 62-year-old male patient has been admitted to the alcoholic referral unit
in the local hospital. Based on an understanding of the effects of alcohol on
the GI tract, which is a priority concern related to nutrition?
a) Vitamin B malnutrition
b) Obesity
c) Dehydration
d) Vitamin C deficiency ✔️Ans - a Vitamin B malnutrition
The need for B vitamins is increased in alcoholics because these nutrients
are used to metabolize alcohol, thus depleting their supply. Alcohol abuse
specifically affects the B vitamins. Obesity, dehydration, and vitamin C
deficiency may be present, but these are not directly related to the effect of
alcohol on the GI tract.
, A nurse is caring for a newly placed gastrostomy tube of a postoperative
patient. Which nursing action is performed correctly?
a) The nurse dips a cotton-tipped applicator into sterile saline solution and
gently cleans around the insertion site.
b) The nurse wets a washcloth and washes the area around the tube with
soap and water.
c) The nurse adjusts the external disk every 3 hours to avoid crusting
around the tube.
d) The nurse tapes a gauze dressing over the site after cleansing it. ✔️Ans
- a) The nurse dips a cotton-tipped applicator into sterile saline solution
and gently cleans around the insertion site.
When caring for a new gastrostomy tube, the nurse would use a cotton-
tipped applicator dipped in sterile saline to gently cleanse the area,
removing any crust or drainage. The nurse would not use a washcloth with
soap and water on a new gastrostomy tube, but may use this method if the
site is healed. Also, once the sutures are removed, the nurse should rotate
the external bumper 90 degrees once a day. The nurse should leave the site
open to air unless there is drainage. If there is drainage, one thickness of
precut gauze should be placed under the external bumper and changed as
needed to keep the area dry.
A nurse is assessing a patient who has been NPO (nothing by mouth) prior
to abdominal surgery. The patient is ordered a clear liquid diet for
breakfast, to advance to a house diet as tolerated. Which assessments
would indicate to the nurse that the patient's diet should not be advanced?
a) The patient consumed 75% of the liquids on her breakfast tray.
b) The patient tells you she is hungry.
c) The patient's abdomen is soft, nondistended, with bowel sounds.
d) The patient reports fullness and diarrhea after breakfast. ✔️Ans - d)
The patient reports fullness and diarrhea after breakfast.
Tolerance of diet can be assessed by the following: absence of nausea,
vomiting, and diarrhea; absence of feelings of fullness; absence of
abdominal pain and distention; feelings of hunger; and the ability to
consume at least 50% to 75% of the food on the meal tray.
