basic exam 5

Which population is most at risk for malnutrition?

Older adults living alone on fixed incomes. Rationale: Social isolation, financial limitations, and chronic illness increase risk for poor nutrition.

Which macronutrient is the primary source of quick energy?

Carbohydrates. Carbs are metabolized rapidly and are the body's preferred energy source for cells and the brain.

Which vitamin is fat-soluble and stored in the body?

Vitamin D. Rationale: Fat-soluble vitamins (A, D, E, K) are stored in adipose tissue and liver for future use.

Combining plant sources of protein to obtain all essential amino acids is known as what?

Protein complementation. Rationale: This strategy ensures adequate intake of essential amino acids when avoiding animal proteins.

A client's BMI is 31. This is classified as what?

Obese. Rationale: A BMI of 30 or greater indicates obesity, increasing risk for heart disease and diabetes.

What is included in a clear-liquid diet?

Broth, tea, gelatin, clear juices, and popsicles. Rationale: These foods are transparent and easily digested; used for pre/post-op and GI rest.

What is the first nursing action if a patient with dysphagia begins coughing while eating?

Stop feeding and assess airway. Rationale: Coughing indicates aspiration risk; airway safety is the priority.

Which lab finding best reflects protein status?

Serum albumin. Rationale: Low albumin indicates malnutrition or poor protein intake.

Which factor most influences food choices and eating habits?

Cultural and religious beliefs. Rationale: Nutrition patterns are deeply rooted in cultural and spiritual traditions.

Which population group commonly experiences nutritional risk due to substance use?

People with alcohol use disorder. Rationale: Alcohol interferes with absorption of vital nutrients, especially B vitamins.

What vitamin deficiency causes scurvy?

Vitamin C. Rationale: Vitamin C is required for collagen formation; deficiency causes bleeding gums and poor wound healing.

What is the function of dietary fiber?

Promotes bowel regularity and lowers cholesterol. Rationale: Fiber increases stool bulk and aids in reducing serum cholesterol.

Which food is a complete protein?

Eggs. Rationale: Complete proteins contain all essential amino acids and are found in animal products.

What is the safest position for feeding a client with dysphagia?

Upright sitting position (90°). Rationale: Promotes swallowing and prevents aspiration.

Which mineral deficiency causes anemia?

Iron. Rationale: Iron is essential for hemoglobin synthesis and oxygen transport.

Which fat-soluble vitamin aids in blood clotting?

Vitamin K. Rationale: Vitamin K is necessary for synthesis of prothrombin.

What nutrient helps with tissue repair and wound healing?

Protein. Rationale: Protein supports tissue regeneration and immune function.

What should a nurse assess before recommending a high-protein diet?

Kidney function. Rationale: Excess protein intake can stress renal function and cause azotemia.

Which diet would be most appropriate for a patient after jaw surgery?

Full liquid diet. Rationale: Provides adequate nutrition while avoiding chewing.

A patient states, "I don't have time to cook healthy meals." What factor affects nutrition here?

Time available for food preparation. Rationale: Limited time is a major influence on dietary habits.

The nurse observes a patient with fluid overload. Which finding is expected?

Crackles in lung bases. Rationale: Fluid excess increases pulmonary capillary pressure, leading to edema and crackles.

Which electrolyte imbalance is most likely in a patient with prolonged vomiting?

Hypokalemia. Rationale: Potassium is lost with gastric secretions; replacement and monitoring are required.

What is the function of osmosis?

Movement of water through a semipermeable membrane from low to high solute concentration. Rationale: Osmosis maintains fluid balance across cellular membranes.

What does a hypotonic IV solution do to cells?

Causes water to move into cells, leading to cellular swelling. Rationale: Hypotonic fluids have fewer solutes than plasma and rehydrate cells.

What effect does a hypertonic IV solution have on cells?

Causes water to move out of cells, leading to cellular shrinkage. Rationale: Hypertonic fluids draw water from cells into the intravascular space.

What is the most accurate way to assess a patient's fluid balance?

Daily weights. Rationale: 1 kg of weight gain/loss equals 1 L of fluid retained or lost.

What is third spacing?

Fluid shifts from intravascular to interstitial spaces. Rationale: Fluid becomes trapped and unavailable for circulation, causing edema and hypotension.

Which IV complication is indicated by cool, pale skin and swelling at the site?

Infiltration. Rationale: Fluid has leaked into surrounding tissues; stop infusion and elevate limb.

What is the first action if a patient develops chills and fever during a blood transfusion?

Stop the transfusion immediately. Rationale: These are signs of a transfusion reaction; stopping prevents further reaction.

Which type of nutrition provides complete nutrients intravenously when oral intake is not possible?

Total Parenteral Nutrition (TPN).Rationale: TPN supplies all essential nutrients via central line when GI tract cannot be used.

Which mechanism moves substances from low to high concentration using energy (ATP)?

Active transport. Rationale: Unlike diffusion, active transport requires energy to move substances against their gradient.

Which IV solution is isotonic?

0.9% Normal Saline (NS). Rationale: Isotonic solutions maintain equal osmotic pressure and expand intravascular volume.

The nurse identifies crackles and dyspnea in a patient receiving IV fluids at 150 mL/hr. What should the nurse do?

Slow the infusion rate and notify the provider. Rationale: Signs of circulatory overload require prompt adjustment to prevent pulmonary edema.

Which IV device is used for intermittent medication administration?

Saline lock (intermittent venous access device). Rationale: Allows periodic medication without continuous IV infusion.

What is the safest IV site for an adult client?

Dorsal hand or forearm vein. Rationale: These sites are accessible, easy to monitor, and have low complication risk.

What's the primary purpose of measuring intake and output (I&O)?

To monitor fluid balance and detect imbalances early. Rationale: Accurate I&O measurement helps prevent dehydration or fluid overload.

What is a potential complication of total parenteral nutrition (TPN)?

Infection. Rationale: Central line access increases risk for bloodstream infections; sterile technique is vital.

Which lab result indicates dehydration?

High hematocrit. Rationale: Hemoconcentration from fluid loss elevates Hct levels.

Which client is at greatest risk for hypovolemia?

Client with severe burns. Rationale: Burns cause massive fluid shifts and third spacing.

What is the primary function of sodium in the body?

Maintains fluid balance and nerve conduction. Rationale: Sodium controls extracellular fluid and influences muscle contraction.

Which electrolyte imbalance can cause cardiac dysrhythmia's?

Potassium imbalance. Rationale: Both hypokalemia and hyperkalemia can lead to arrhythmias.

What is the best nursing intervention for a patient on fluid restriction?

Offer frequent mouth care and ice chips. Rationale: Relieves thirst and promotes comfort without exceeding restriction.

What complication occurs when IV fluid enters surrounding tissue causing pain and swelling?

Extravasation. Rationale: Vesicant fluid damages tissues; stop infusion and notify provider.

What is the correct nursing action if phlebitis develops at an IV site?

Discontinue the IV and apply a warm compress.Rationale: Prevents further inflammation and promotes comfort.

What is the priority nursing assessment during blood transfusion?

Vital signs. Rationale: Detects early signs of transfusion reaction or circulatory overload.

Which transfusion reaction is caused by antigen-antibody incompatibility?

Hemolytic reaction. Rationale: Results from incompatible blood; causes fever, chills, flank pain, hypotension.

What type of solution is Lactated Ringer's?

Isotonic. Rationale: Used to replace fluid and electrolytes lost from surgery, burns, or trauma.

What are signs of hypovolemia?

Hypotension, weak pulse, dry mucous membranes. Rationale: Fluid loss reduces circulating volume and tissue perfusion.

What are signs of hypervolemia?

Edema, crackles, bounding pulse, hypertension. Rationale: Fluid loss reduces circulating volume and tissue perfusion.

Which IV solution expands plasma volume without moving water into or out of cells?

0.9% Normal Saline (Isotonic). Rationale: Replaces extracellular fluid and maintains osmotic balance.