NURS 225 Exam 4 V1 | NURS 225 Nutrition
Proctored Exam | Actual Q&A with
Rationale (NURS225 Exam 4) | West Coast
University
1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a
central venous access device. Which of the following actions should the nurse take to prevent
the complication of air embolism?
A. Instruct the client to take deep breaths during tubing changes.
B. Maintain the infusion pump at a high pressure setting.
C. Place the client in the high-Fowler’s position during the procedure.
D. Ask the client to perform the Valsalva maneuver during dressing or tubing changes.
Answer: D
Rationale: The Valsalva maneuver increases intrathoracic pressure, which prevents air
from entering the central circulation when the catheter is open. This technique is a
standard safety protocol during central line maintenance. Failure to perform this action
significantly increases the risk of a fatal air embolism in critically ill patients.
2. A client with chronic kidney disease (CKD) is prescribed a diet restricted in potassium.
Which of the following food choices should the nurse instruct the client to avoid?
A. Apples and blueberries.
,B. Bananas and baked potatoes.
C. White bread and rice.
D. Green beans and cabbage.
Answer: B
Rationale: Bananas and potatoes are high-potassium foods that can lead to hyperkalemia
in patients with impaired renal function. Hyperkalemia is a life-threatening condition that
can cause cardiac dysrhythmias and arrest. Clients with CKD must be educated on choosing
low-potassium alternatives like apples or berries.
3. A nurse is planning care for a client who has a prescription for a clear liquid diet. Which of
the following items should the nurse include on the client’s meal tray?
A. Apple juice and gelatin.
B. Orange juice with pulp.
C. Sherbet.
D. Vanilla pudding.
Answer: A
Rationale: Clear liquids must be transparent and liquid at room temperature, such as
apple juice, broth, and gelatin. Items like pudding or sherbet contain dairy and are
considered part of a full liquid diet. This dietary stage is typically used post-operatively to
test gastrointestinal tolerance before advancing to solid foods.
, 4. Which of the following interventions should the nurse perform for a client experiencing
dumping syndrome following a gastrectomy?
A. Encourage the client to drink 240 mL of water with each meal.
B. Provide three large meals per day to ensure adequate caloric intake.
C. Advise the client to lie down for 30 minutes after eating.
D. Increase the intake of simple carbohydrates like honey and syrup.
Answer: C
Rationale: Lying down after meals slows the transit of food from the stomach into the
small intestine, which reduces the symptoms of dumping syndrome. Clients should also be
taught to avoid fluids with meals and consume small, frequent portions. Reducing simple
sugars helps prevent the rapid osmotic shift that causes the dizziness and palpitations
associated with this condition.
5. A nurse is educating a client with Type 2 Diabetes Mellitus about carbohydrate counting.
Which of the following statements by the client indicates an understanding of the teaching?
A. One carbohydrate serving is equal to 15 grams of carbohydrates.
B. I should avoid all carbohydrates to keep my blood sugar low.
C. I can eat as much protein as I want because it doesn’t affect my glucose.
D. I should only count simple sugars and ignore fiber in my count.
Answer: A
Proctored Exam | Actual Q&A with
Rationale (NURS225 Exam 4) | West Coast
University
1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a
central venous access device. Which of the following actions should the nurse take to prevent
the complication of air embolism?
A. Instruct the client to take deep breaths during tubing changes.
B. Maintain the infusion pump at a high pressure setting.
C. Place the client in the high-Fowler’s position during the procedure.
D. Ask the client to perform the Valsalva maneuver during dressing or tubing changes.
Answer: D
Rationale: The Valsalva maneuver increases intrathoracic pressure, which prevents air
from entering the central circulation when the catheter is open. This technique is a
standard safety protocol during central line maintenance. Failure to perform this action
significantly increases the risk of a fatal air embolism in critically ill patients.
2. A client with chronic kidney disease (CKD) is prescribed a diet restricted in potassium.
Which of the following food choices should the nurse instruct the client to avoid?
A. Apples and blueberries.
,B. Bananas and baked potatoes.
C. White bread and rice.
D. Green beans and cabbage.
Answer: B
Rationale: Bananas and potatoes are high-potassium foods that can lead to hyperkalemia
in patients with impaired renal function. Hyperkalemia is a life-threatening condition that
can cause cardiac dysrhythmias and arrest. Clients with CKD must be educated on choosing
low-potassium alternatives like apples or berries.
3. A nurse is planning care for a client who has a prescription for a clear liquid diet. Which of
the following items should the nurse include on the client’s meal tray?
A. Apple juice and gelatin.
B. Orange juice with pulp.
C. Sherbet.
D. Vanilla pudding.
Answer: A
Rationale: Clear liquids must be transparent and liquid at room temperature, such as
apple juice, broth, and gelatin. Items like pudding or sherbet contain dairy and are
considered part of a full liquid diet. This dietary stage is typically used post-operatively to
test gastrointestinal tolerance before advancing to solid foods.
, 4. Which of the following interventions should the nurse perform for a client experiencing
dumping syndrome following a gastrectomy?
A. Encourage the client to drink 240 mL of water with each meal.
B. Provide three large meals per day to ensure adequate caloric intake.
C. Advise the client to lie down for 30 minutes after eating.
D. Increase the intake of simple carbohydrates like honey and syrup.
Answer: C
Rationale: Lying down after meals slows the transit of food from the stomach into the
small intestine, which reduces the symptoms of dumping syndrome. Clients should also be
taught to avoid fluids with meals and consume small, frequent portions. Reducing simple
sugars helps prevent the rapid osmotic shift that causes the dizziness and palpitations
associated with this condition.
5. A nurse is educating a client with Type 2 Diabetes Mellitus about carbohydrate counting.
Which of the following statements by the client indicates an understanding of the teaching?
A. One carbohydrate serving is equal to 15 grams of carbohydrates.
B. I should avoid all carbohydrates to keep my blood sugar low.
C. I can eat as much protein as I want because it doesn’t affect my glucose.
D. I should only count simple sugars and ignore fiber in my count.
Answer: A
