NR 224 Final Exam with All Correct & 100% Verified
Answers |Actual Complete Exam| Guaranteed to Pass
An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the
patient has no teeth and is having a difficulty eating. Which diet should the nurse encourage the
primary health-care provider to order for this patient?
a. liquid supplements
b. mechanical soft
c. pureed
d. soft ✔Correct Answer-b.
rationale: a mechanical soft diet is modified only in texture. It includes moist foods that require
minimal chewing and eliminates most raw fruits and vegetables containing seeds, nuts and dry
fruit... a patient with no teeth can handle more than just pureed food... soft food diet is ordered for
patients who are unable to tolerate a regular diet after surgery.
The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue
repair?
a. fat
b. proteins
c. vitamins
d. carbohydrates ✔Correct Answer-b
rationale: proteins help aid with tissue repair and healing
Which action is initially taken by the nurse to verify correct position of a newly placed small-bore
feeding tube?
a. placing an order for x-ray film examination to check position
b. confirming the distal mark on the feeding tube after taping
c. testing the pH of the gastric contents and observing the color
d. auscultating over the gastric area as air is injected into the tube ✔Correct Answer-a.
rationale: an X-ray is the most accurate way to check placement of the tube... you cannot assume the
placement is in the correct place based on the distal mark alone... you NEVER insert air into the
feeding tube to auscultate the placement (although nurses do that.., it is not correct in NCLEX world)
The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which
assessment findings need further intervention?
a. gastric pH of 4.0 during placement check
b. weight gain of 1 lb. over the course of a week
c. active bowel sounds in the four abdominal quadrants
d. gastric residual aspirate of 350 mL for the second consecutive time ✔Correct Answer-d.
rationale: a gastric pH of 4.0 means gastric placement is correct.... weight gain is common for
nutritional supplement tube feedings... active bowel sounds is what you want to hear.... delayed
gastric emptying is a concern if 250 mL or more remains in a patients stomach on TWO
CONSECUATIVE ASSESSMENTS.... if a single GVR measurement exceeds 500 mL CALL PROVIDER
, The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being
checked since he does not have diabetes. What is the best response by the nurse?
a. TPN can cause hyperglycemia, and it is important to keep your blood glucose in an acceptable
range.
b. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be
monitored closely
c. monitoring your blood glucose level helps to determine the dose of insulin that you need to
absorb the TPN
d. checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition
intervention. ✔Correct Answer-a.
rationale: TPN causes hyperglycemia and should be weaned off so the patient does not become
hypoglycemic,
the nurse is checking feeding tube placement. Place the steps in the proper sequence.
1. draw 5 to 10 mL gastric aspirate into syringe.
2. Flush tube with 30 mL air
3. mix aspirate in syringe and place in medicine cup
4. observe color of gastric aspirate
5. perform hand hygiene and put on clean gloves
6. dip pH strip into gastric aspirate
7. compare strip color chart from manufacturer. ✔Correct Answer-5, 2, 1, 4, 3, 6, 7
The home care nurse is seeing the following patients. Which patient is at greatest risk for
experiencing inadequate nutrition?
a. a 55-year old obese man recently diagnosed with diabetes mellitus
b. a recently widowed 76-year-old woman recovering from a mild stroke.
c. a 22 year old mother with a 3-year old toddler who had a tonsillectomy surgery
d. a 46 year old man recovering at home following a coronary artery bypass surgery ✔Correct
Answer-b.
rationale: the woman suffered a stroke and lives alone would be the greatest risk due to possible
immobility issues to get food, and move around the house.
A nurse is providing for the nutritional needs of several patients. Which problems increase patients'
calorie requirements? SELECT ALL THAT APPLY
a. burns
b. nausea
c. dysphagia
d. pneumonia
e. depression ✔Correct Answer-a, d.
rationale: burns interrupt the integrity of the skin and as a result a primary defense against infection
is disrupted. The body's metabolic rate increases dramatically in an attempt to repair the skin and
protect the body from infections. pneumonia is also an infection which would require an increase in
calorie consumption. Nausea, dysphagia and depression does not precipitate for an increase in
calorie consumption
A nurse is caring for a patient receiving bolus enteral feedings several times daily. Which nursing
intervention is MOST important to help prevent diarrhea?
Answers |Actual Complete Exam| Guaranteed to Pass
An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the
patient has no teeth and is having a difficulty eating. Which diet should the nurse encourage the
primary health-care provider to order for this patient?
a. liquid supplements
b. mechanical soft
c. pureed
d. soft ✔Correct Answer-b.
rationale: a mechanical soft diet is modified only in texture. It includes moist foods that require
minimal chewing and eliminates most raw fruits and vegetables containing seeds, nuts and dry
fruit... a patient with no teeth can handle more than just pureed food... soft food diet is ordered for
patients who are unable to tolerate a regular diet after surgery.
The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue
repair?
a. fat
b. proteins
c. vitamins
d. carbohydrates ✔Correct Answer-b
rationale: proteins help aid with tissue repair and healing
Which action is initially taken by the nurse to verify correct position of a newly placed small-bore
feeding tube?
a. placing an order for x-ray film examination to check position
b. confirming the distal mark on the feeding tube after taping
c. testing the pH of the gastric contents and observing the color
d. auscultating over the gastric area as air is injected into the tube ✔Correct Answer-a.
rationale: an X-ray is the most accurate way to check placement of the tube... you cannot assume the
placement is in the correct place based on the distal mark alone... you NEVER insert air into the
feeding tube to auscultate the placement (although nurses do that.., it is not correct in NCLEX world)
The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which
assessment findings need further intervention?
a. gastric pH of 4.0 during placement check
b. weight gain of 1 lb. over the course of a week
c. active bowel sounds in the four abdominal quadrants
d. gastric residual aspirate of 350 mL for the second consecutive time ✔Correct Answer-d.
rationale: a gastric pH of 4.0 means gastric placement is correct.... weight gain is common for
nutritional supplement tube feedings... active bowel sounds is what you want to hear.... delayed
gastric emptying is a concern if 250 mL or more remains in a patients stomach on TWO
CONSECUATIVE ASSESSMENTS.... if a single GVR measurement exceeds 500 mL CALL PROVIDER
, The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being
checked since he does not have diabetes. What is the best response by the nurse?
a. TPN can cause hyperglycemia, and it is important to keep your blood glucose in an acceptable
range.
b. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be
monitored closely
c. monitoring your blood glucose level helps to determine the dose of insulin that you need to
absorb the TPN
d. checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition
intervention. ✔Correct Answer-a.
rationale: TPN causes hyperglycemia and should be weaned off so the patient does not become
hypoglycemic,
the nurse is checking feeding tube placement. Place the steps in the proper sequence.
1. draw 5 to 10 mL gastric aspirate into syringe.
2. Flush tube with 30 mL air
3. mix aspirate in syringe and place in medicine cup
4. observe color of gastric aspirate
5. perform hand hygiene and put on clean gloves
6. dip pH strip into gastric aspirate
7. compare strip color chart from manufacturer. ✔Correct Answer-5, 2, 1, 4, 3, 6, 7
The home care nurse is seeing the following patients. Which patient is at greatest risk for
experiencing inadequate nutrition?
a. a 55-year old obese man recently diagnosed with diabetes mellitus
b. a recently widowed 76-year-old woman recovering from a mild stroke.
c. a 22 year old mother with a 3-year old toddler who had a tonsillectomy surgery
d. a 46 year old man recovering at home following a coronary artery bypass surgery ✔Correct
Answer-b.
rationale: the woman suffered a stroke and lives alone would be the greatest risk due to possible
immobility issues to get food, and move around the house.
A nurse is providing for the nutritional needs of several patients. Which problems increase patients'
calorie requirements? SELECT ALL THAT APPLY
a. burns
b. nausea
c. dysphagia
d. pneumonia
e. depression ✔Correct Answer-a, d.
rationale: burns interrupt the integrity of the skin and as a result a primary defense against infection
is disrupted. The body's metabolic rate increases dramatically in an attempt to repair the skin and
protect the body from infections. pneumonia is also an infection which would require an increase in
calorie consumption. Nausea, dysphagia and depression does not precipitate for an increase in
calorie consumption
A nurse is caring for a patient receiving bolus enteral feedings several times daily. Which nursing
intervention is MOST important to help prevent diarrhea?
