Chapter 24: Nutritional Care and Support

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A nurse is determining a patient’s intake and output. Which finding should be included in the intake
measurement?
1. All beverages consumed during the shift
2. Amount of food eaten on trays
3. Pudding eaten as a snack
4. Medication given in liquid form
____ 2. An LPN/LVN caring for a patient with diabetes mellitus obtains a morning blood glucose level of 60 mg/dL.
The LPN/LVN reports the finding to the RN. Which intervention would the LPN/LVN expect?
1. Provide the patient with half a cup of orange juice.
2. Cover the patient with insulin using a sliding scale.
3. Chart the finding in the patient’s medical record.
4. Wait for 15 minutes and repeat the assessment.
____ 3. A nurse is taking care of a patient who reports diarrhea and flatulence associated with the intake of dairy
products. How should the nurse interpret these findings?
1. Celiac disease
2. Food allergy
3. Food intolerance
4. Vitamin deficiency
____ 4. A patient has been admitted to the medical unit for a 23-hour observation following a motor vehicle accident
(MVA) to assess for concussion. Glasgow Coma Scale results are 4E, 3V, and 4M. Which diet would the
nurse anticipate that the health-care provider (HCP) will order?
1. Clear liquid
2. Mechanical soft
3. Regular
4. NPO
____ 5. A patient has ill-fitting dentures but denies any problems with eating foods. What type of diet selection would
the nurse anticipate that the health-care provider (HCP) will order?
1. Mechanical soft
2. Full liquid
3. Regular
4. Pureed
____ 6. A patient is admitted for bowel surgery. Which type of diet selection would the nurse anticipate that the
health-care provider (HCP) will order prior to surgery?
1. Protein restricted
2. Sodium restricted
3. Fiber restricted
4. High calorie, high protein
____ 7. A nurse is teaching a patient newly diagnosed with diabetes mellitus about the eating and nutrition parameters
required with the patient’s diagnosis. Which comment by the patient indicates that teaching is understood?
1. “I will need to eat 3 meals and 2 snacks daily.”
2. “I can plan for a special dinner if I skip my lunch.”

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 3. “I will find a new method for cooking besides frying.”
4. “Once a week I can splurge and eat whatever I want.”
____ 8. A nurse is admitting a patient for a diagnosis unrelated to nutrition; however, the patient states, “I don’t eat
gluten, but I don’t have celiac disease.” Which meal would the nurse expect the patient to order?
1. Bean soup, cornbread with butter, and tapioca pudding
2. Ham and cheese sandwich on whole-wheat bread and fruit
3. Spaghetti with meat sauce, salad, and cake with butter frosting
4. Baked chicken breast, mashed potatoes with butter, and ice cream
____ 9. A nurse is providing care for a patient after joint replacement surgery. The nurse delivers a lunch tray with a
cheeseburger, French fries, slaw, and fresh fruit. After the meal, the nurse picks up an empty tray. Which
comment is more important for the nurse to make if the patient states, “My husband ate part of my lunch
because I’m just not that hungry”?
1. “That’s fine. Most of our patients do not eat all their meals.”
2. “I will need to know which foods you actually ate.”
3. “The trays are overfilled, so patients have plenty to eat.”
4. “Let’s discuss what foods you would like for the next meal.”
____ 10. A patient is prescribed isoniazid (INH), a medication that treats tuberculosis (TB). Which condition will
prompt the nurse to remind the physician that the patient will need a specific vitamin during the therapy?
1. Vitamin K is not absorbed when a patient has TB.
2. Vitamin C will increase lung healing with TB.
3. Vitamin B6 excretion will increase with INH.
4. Vitamin B12 prevents nerve damage from INH.
____ 11. A patient is prescribed the medication lithium as a mood-stabilizing agent. Which laboratory report indicates
the patient may be retaining higher-than-prescribed levels of lithium?
1. Low sodium levels
2. High sodium levels
3. Low potassium levels
4. High potassium levels
____ 12. A patient is in the emergency room with coffee ground emesis. What priority order would the nurse
anticipate from the health-care provider (HCP)?
1. 1 unit PRBCs
2. CBC and chemistry
3. Initiate IV access
4. Insert nasogastric tube
____ 13. A nurse assesses a patient 24 hours after abdominal surgery. The patient has nausea and anorexia and is
vomiting foul-smelling emesis. Physical assessment reveals a distended abdomen and hypoactive bowel
sounds. Which order would the nurse expect from the health-care provider (HCP)?
1. A nasogastric tube inserted to provide enteral nutrition
2. A prescription for antinausea and antiemetic medication
3. A schedule of six small liquid meals to be given daily
4. A nasogastric tube inserted for gastric decompression
____ 14. A nurse is preparing to insert a nasogastric tube (NG). Which finding if observed by the nurse manager
indicates that additional teaching is needed to perform this skill?
1. Head of bed (HOB) has been raised.
2. A water-soluble lubricant has been used.
3. Patient has been draped.

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 4. A 10 mL syringe is at bedside for irrigation.
____ 15. When the nurse inserts a nasogastric (NG) tube, the patient becomes cyanotic, coughs incessantly, and is
unable to speak. Which action should the nurse take immediately?
1. Encourage swallowing.
2. Continue to insert the tube.
3. Remove the tube completely.
4. View the posterior pharynx.
____ 16. A nurse is completing the placement of a nasogastric (NG) tube. Which nursing action would lead to a
potential complication when securing the tube?
1. Apply small pieces of tape to secure the NG tube.
2. Use 2 pieces of tape to secure the NG tube.
3. Partially block nares when applying to stabilize NG tube.
4. Hold NG tube in place prior to securing with tape.
____ 17. A patient tells the nurse of minor gastrointestinal pain, flatulence, and diarrhea several times after meals.
Which possible cause should the nurse identify?
1. Anaphylaxis
2. Food intolerance
3. Food allergy
4. Food poisoning
____ 18. A patient is receiving intermittent enteral feedings. What priority action should the nurse implement after a
feeding?
1. Check placement.
2. Maintain head of bed (HOB) at 30 to 40 degrees.
3. Check residual.
4. Check patency of tubing.
____ 19. A nurse is verifying placement of a nasogastric tube (NG) prior to starting continuous tube feedings. The
patient had previously been on intermittent tube feedings. Which action could lead to potential complications?
1. Verifying placement using stethoscope
2. Verifying health-care provider (HCP) order
3. Making sure that solution is at room temperature
4. Not checking for residual volume
____ 20. A nurse is reviewing the patient’s intake for lunch. The patient had 2 cups of coffee, a large bowl of soup, and
half a carton of milk. Based on this information, how should the nurse document fluid intake?
1. 500 mL
2. 600 mL
3. 660 mL
4. 540 mL

Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 21. A nurse is admitting a patient with a clinical diagnosis of anorexia nervosa. What clinical findings should the
nurse anticipate being present? Select all that apply.
1. Gastric reflux
2. Irregular menstrual cycle
3. Decreased skin turgor

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 4. Muscle wasting
5. Decreased grip strength
____ 22. A group of nursing students are reviewing binge eating disorder. Which findings are accurate as they relate to
this condition? Select all that apply.
1. No purging is found.
2. It is seen in patients with BMI 25 and above.
3. It affects males greater than females.
4. Psychological attributes are attached to behavior.
5. It is a treatable condition.
____ 23. A health-care provider (HCP) has ordered “Clear liquids, advance as tolerated.” Which factors indicate to the
nurse the advancement of the patient’s diet should be delayed? Select all that apply.
1. Hypoactive bowel sounds
2. Nausea and vomiting
3. Reports of indigestion
4. Expression of hunger
5. Verbalizing thirst
____ 24. A nurse is monitoring a patient who has a nasogastric (NG) tube set to low continuous suction. Which
responsibilities should the nurse include in the plan of care? Select all that apply.
1. Check tubing connections.
2. Offer the patient increased fluids.
3. Auscultate bowel sounds every 4 hours.
4. Provide oral care.
5. Monitor I&O.
____ 25. A nurse is reviewing solutions that can be used to provide partial parenteral nutrition (PPN). Which
characteristics do PPN solutions have? Select all that apply.
1. Contain at least 25% dextrose
2. Isotonic
3. Contain less than 5% amino acids
4. Limited calories
5. Lipids

Completion
Complete each statement.

26. A patient’s stomach contents will be removed by inserting a double-lumen nasogastric (NG) tube through the
nose into the stomach and then connecting the tube to a suction. The nurse identifies this procedure as
____________________.

27. When a patient has an intact digestive system but has difficulty with swallowing, digestion, or absorption of
food, the nurse can expect the patient to be ordered ____________________ feedings.

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apter 24: Nutritional Care and Support
Answer Section

MULTIPLE CHOICE

1. ANS: 1
Chapter: Chapter 24, Nutritional Care and Support
Objective: 3. Explain how to monitor intake and output and why it is important.
Page: 448
Heading: Monitoring Intake and Output
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment | Fluids and Electrolytes
Difficulty: Difficult
Feedback
1 This is correct. Intake is composed of fluids taken by mouth, those administered IV,
and fluids administered by enteral or parenteral feedings
2 This is incorrect. The amount of food eaten on the tray is not measured as intake but
recorded as nutritional consumption/appetite.
3 This is incorrect. Pudding eaten as snacks are not recorded as intake but recorded as
nutritional consumption/appetite.
4 This is incorrect. Intake is composed of fluids taken by mouth, those administered IV,
and fluids administered by enteral or parenteral feedings. Oral liquid medications are
not included in this measurement.

PTS: 1 CON: Clinical Judgment | Fluids and Electrolytes

2. ANS: 1
Chapter: Chapter 24, Nutritional Care and Support
Objective: 6. Describe the nurse’s responsibilities for patients on special diets, including diabetics and their
specific needs.
Page:453
Heading: Patients With Diabetes
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment |Nutrition
Difficulty: Difficult
Feedback
1 This is correct. The 2018 American Diabetes Association guidelines state a range of 80
to 130 mg/dL before meals is acceptable for patients with existing diabetes. A blood
glucose level of 60 mg/dL is consistent with hypoglycemia, and the patient should be
provided with a fast-acting carbohydrate, such as orange juice.
2 This is incorrect. A blood glucose level of 60 mg/dL is consistent with hypoglycemia,
and the patient does not need additional insulin, which would further lower the blood
glucose level.
3 This is incorrect. A blood glucose level of 60 mg/dL is not within normal range but is
consistent with hypoglycemia. The LPN/LVN will chart the blood glucose level.
However, an additional intervention is expected.

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 4 This is incorrect A blood glucose level of 60 mg/dL is consistent with hypoglycemia.
Waiting 15 minutes and then checking the blood glucose level without providing a fast-
acting carbohydrate will likely get the same or lower result.

PTS: 1 CON: Clinical Judgment | Nutrition

3. ANS: 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 1. Define various terms associated with nutritional care and support.
Page: 449-450
Heading: Food Intolerances
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Clinical Judgment | Nutrition
Difficulty: Moderate

Feedback
1 This is incorrect. Celiac disease is related to the inability to digest gluten. Lactose
intolerance is related to the inability to digest dairy products.
2 This is incorrect. There is no clinical evidence of a food allergy.
3 This is correct. Lactose intolerance is related to the inability to digest dairy products.
Food intolerance is not an allergic reaction; it is an adverse reaction to a food without
activation of the immune response.
4 This is incorrect. There is no clinical evidence to suggest a vitamin deficiency.

PTS: 1 CON: Clinical Judgment |Nutrition

4. ANS: 4
Chapter: Chapter 24, Nutritional Care and Support
Objective: Describe NPO status, regular diets, and diets modified by consistency.
Page: 450
Heading: Therapeutic Diets > NPO
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment |Nutrition
Difficulty: Difficult
Feedback
1 This is incorrect. Based on the presenting Glasgow Coma Scale (4E, 3V, 4M) total of
11, the patient should not be given anything by mouth because their verbal response is
inappropriate and their motor response is that they withdraw from painful stimuli. The
patient should be kept NPO.
2 This is incorrect. Based on the presenting Glasgow Coma Scale (4E, 3V, 4M) total of
11, the patient should not be given anything by mouth because their verbal response is
inappropriate and their motor response is that they withdraw from painful stimuli. The
patient should be kept NPO.
3 This is incorrect. Based on the presenting Glasgow Coma Scale (4E, 3V, 4M) total of
11, the patient should not be given anything by mouth because their verbal response is
inappropriate and their motor response is that they withdraw from painful stimuli. The
patient should be kept NPO.
4 This is correct. Based on the presenting Glasgow Coma Scale (4E, 3V, 4M) total of 11,

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 the patient should not be given anything by mouth because their verbal response is
inappropriate and their motor response is that they withdraw from painful stimuli. The
patient should be kept NPO.

PTS: 1 CON: Clinical Judgment |Nutrition

5. ANS: 1
Chapter: Chapter 24, Nutritional Care and Support
Objective: 4. Describe NPO status, regular diets, and diets modified by consistency.
Page: 450-451
Heading: Diets Modified by Consistency
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Clinical Judgment | Nutrition
Difficulty: Moderate
Feedback
1 This is correct. A mechanical soft diet is the diet of choice for patients with acute or
chronic difficulties with chewing, such as those with jaw problems, missing teeth,
poorly fitting dentures, or severe weakness or fatigue.
2 This is incorrect. A full liquid diet consists of all the liquids found in a clear liquid diet
with the addition of all other opaque liquids and food items that become liquid at room
temperature. The patient does not require this type of diet.
3 This is incorrect. A regular diet is appropriate for patients without special nutritional
needs. Because the patient has ill-fitting dentures, a modified diet is required.
4 This is incorrect. A pureed diet is one that is processed in a blender or food processor.
The patient does not require this type of diet.

PTS: 1 CON: Clinical Judgment |Nutrition

6. ANS: 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 5. Describe diets modified for diseases and preferences.
Page: 452
Heading: Diets Modified for Disease
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Clinical Judgment |Nutrition
Difficulty: Moderate
Feedback
1 This is incorrect. A protein-restricted diet is indicated for patients with liver or kidney
disease.
2 This is incorrect. A sodium-restricted diet is indicated for patients with hypertension,
heart failure, or kidney or liver failure, as well as for those who require help to prevent
or correct fluid retention.
3 This is correct. A fiber-restricted diet is used during the acute phase of intestinal
disorders when the presence of fiber may exacerbate intestinal pain, produce diarrhea,
or cause an intestinal blockage. This diet is often used before intestinal surgery to
minimize fecal volume or after surgery to allow the GI system to transition gradually to
a regular diet.
4 This is incorrect. A high-calorie, high-protein diet is used to increase calorie and

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 protein intake in patients with increased need related to wound healing, growth
promotion, and increasing or maintaining weight. High-fat foods also may be added to
increase calories available for energy use.

PTS: 1 CON: Clinical Judgment | Nutrition

7. ANS: 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 17. Discuss information found in the Connection features in this chapter.
Page: 454
Heading: Patient Teaching Connection: Diabetes
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Nutrition | Teaching and Learning
Difficulty: Moderate
Feedback
1 This is incorrect. The patient with diabetes mellitus should eat 3 meals during the day
and 1 evening snack. The comment indicates a lack of understanding.
2 This is incorrect. The patient should eat regularly in order to maintain a more consistent
blood glucose level. The comment indicates a lack of understanding.
3 This is correct. The patient will need a balanced diet consisting of carbohydrates,
moderate protein, and fats in sparingly amounts. When the patient identifies that a new
method of cooking besides frying is needed, the patient is indicating understanding.
4 This is incorrect. The patient should make every effort to eat a well-balanced meal
every day. A day of splurging can put the patient in danger of hyperglycemia. The
comment indicates a lack of understanding.

PTS: 1 CON: Nutrition | Teaching and Learning

8. ANS: 4
Chapter: Chapter 24, Nutritional Care and Support
Objective: 5. Describe diets modified for diseases and preferences.
Page: 452
Heading: Diets Modified by Preference > Gluten-Free Diets
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment | Nutrition
Difficulty: Difficult
Feedback
1 This is incorrect. A patient who prefers not to eat gluten would not select cornbread;
however, the bean soup and tapioca pudding are both gluten free.
2 This is incorrect. A patient who prefers not to eat gluten would not select a sandwich
made with any wheat-based bread, including whole wheat. The ham, cheese, and fruit
are acceptable selections.
3 This is incorrect. Although some pastas do not contain gluten, that information is not
supplied in this scenario. Therefore, a patient who prefers not to eat gluten would avoid
spaghetti and cake. The meat sauce is an appropriate selection.
4 This is correct. A patient who prefers not to eat gluten would be correct in selecting a
baked chicken breast, mashed potatoes with butter, and ice cream. None of these foods
contain gluten.

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 PTS: 1 CON: Clinical Judgment | Nutrition
9. ANS: 2
Chapter: Chapter 24, Nutritional Care and Support
Objective: 6. Describe the nurse’s responsibilities for patients on special diets, including diabetics and their
specific needs.
Page: 453
Heading: Nursing Responsibilities
Integrated Processes: Communication and Documentation
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Communication | Nutrition
Difficulty: Difficult
Feedback
1 This is incorrect. This comment by the nurse does not address the patient’s nutritional
status.
2 This is correct. The nurse’s primary concern is what the patient did eat because the
nurse is aware that the patient will need a balanced diet high in protein, calories, and
vitamin C to promote healing.
3 This is incorrect. The food trays in a hospital are monitored by a dietitian to ensure that
each patient gets a diet that is appropriate for the individual and their needs. The
amount of food served should reflect properly sized portions.
4 This is incorrect. Suggesting that the nurse and patient discuss foods for the next meal
is a means of providing the patient with a diet that is appealing and nutritious.
However, it is more important for the nurse to determine the patient’s current
nutritional intake.

PTS: 1 CON: Communication | Nutrition

10. ANS: 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 9. Describe how drugs can affect food intake, absorption, metabolism, and excretion of nutrients.
Page: 457
Heading: Drug Effects on Excretion of Nutrients
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1 This is incorrect. INH therapy does not prevent vitamin K from being absorbed.
2 This is incorrect. INH therapy does not have anything to do with vitamin C. The
amount of vitamin C can be increased but will have little or no effect during the
treatment of TB.
3 This is correct. Patients receiving INH therapy should be prescribed vitamin B 6 at the
time INH is started. If a patient is treated for more than 6 months, INH can lead to
vitamin B6 deficiency.
4 This is incorrect. INH therapy can lead to vitamin B6 deficiency but is not related to
nerve damage.

PTS: 1 CON: Safety

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11. ANS: 1
Chapter: Chapter 24, Nutritional Care and Support
Objective: 9. Describe how drugs can affect food intake, absorption, metabolism, and excretion of nutrients.
Page: 457
Heading: Drug Effects on Excretion of Nutrients
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1 This is correct. Because lithium and sodium have similar molecular structures, if the
patient has a low sodium level, more lithium will be absorbed, placing the patient at
risk for being overmedicated.
2 This is incorrect. A patient with a high level of sodium will excrete high levels of
sodium and also lithium, which can lead to subtherapeutic levels of the medication.
3 This is incorrect. When administering lithium to a patient, the nurse does not need to
monitor the patient’s potassium.
4 This is incorrect. When administering lithium to a patient, the nurse does not need to
monitor the patient’s potassium.

PTS: 1 CON: Safety

12. ANS: 4
Chapter: Chapter 24, Nutritional Care and Support
Objective: 11. Explain when and how nasogastric tubes are used for gastric decompression.
Page: 459
Heading: Gastric Decompression
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment
Difficulty: Difficult
Feedback
1 This is incorrect. Although PRBC may be warranted, the priority order is to insert a
nasogastric tube to decompress the stomach because coffee ground emesis indicates
blood that has been exposed to stomach acid; it has come from the esophagus and upper
stomach and has reached the lower stomach and been mixed with stomach acid.
2 This is incorrect. Although CBC and chemistry will be needed, the priority order is to
insert a nasogastric tube to decompress the stomach because coffee ground emesis
indicates blood that has been exposed to stomach acid; it has come from the esophagus
and upper stomach and has reached the lower stomach and been mixed with stomach
acid.
3 This is incorrect. Although IV access will be needed, the priority order is to insert a
nasogastric tube to decompress the stomach because coffee ground emesis indicates
blood that has been exposed to stomach acid; it has come from the esophagus and upper
stomach and has reached the lower stomach and been mixed with stomach acid.
4 This is correct. The priority order is to insert a nasogastric tube to decompress the
stomach because coffee ground emesis indicates blood that has been exposed to
stomach acid; it has come from the esophagus and upper stomach and has reached the
lower stomach and been mixed with stomach acid.

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 PTS: 1 CON: Clinical Judgment
13. ANS: 4
Chapter: Chapter 24, Nutritional Care and Support
Objective: 11. Explain when and how nasogastric tubes are used for gastric decompression.
Page: 459
Heading: Gastric Decompression
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment
Difficulty: Difficult
Feedback
1 This is incorrect. The nurse should recognize that the patient is exhibiting the symptoms
related to paralytic ileus. Providing enteral nutrition will worsen the existing condition.
2 This is incorrect. A prescription for antinausea and antiemetic medication treats the
patient’s symptoms but not the cause. The nurse should expect treatment of the cause.
3 This is incorrect. The patient has classic symptoms of paralytic ileus. Twenty-four
hours after surgery, the patient is likely to be on a clear liquid diet. Changing the
schedule to six small liquid meals a day will worsen the existing condition.
4 This is correct. The patient has classic symptoms related to paralytic ileus. The nurse
should expect the physician to order the placement of a nasogastric tube for gastric
decompressing. The tube will be maintained until active bowel sounds are heard.

PTS: 1 CON: Clinical Judgment

14. ANS: 4
Chapter: Chapter 24, Nutritional Care and Support
Objective: 19. Answer questions about the skills in this chapter.
Page: 477-478
Heading: Skill 24.3 Inserting a Nasogastric Tube
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
1 This is incorrect. The HOB should be raised so that the patient is in a sitting or high
Fowler’s position for NG insertion.
2 This is incorrect. Water-soluble lubricant is used during NG insertion.
3 This is incorrect. The patient should be draped prior to NG insertion.
4 This is correct. The nurse should use an irrigation syringe, which is typically 60 mL
rather than 10 mL.

PTS: 1 CON: Safety

15. ANS: 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 18. Identify specific safety information.
Page: 460
Heading: Inserting an NG tube
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)

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 Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment | Safety
Difficulty: Moderate
Feedback
1 This is incorrect. If the patient cannot speak, becomes cyanotic, or coughs incessantly,
the tube is likely to be in the lungs. The nurse should immediately remove the tube and
not encourage swallowing.
2 This is incorrect. If the patient cannot speak, becomes cyanotic, or coughs incessantly,
the tube is likely to be in the lungs. The nurse should not continue to insert the tube.
3 This is correct. If the patient cannot speak, becomes cyanotic, or coughs incessantly, the
tube is likely to be in the lungs. The nurse should immediately remove the tube.
4 This is incorrect. If the patient cannot speak, becomes cyanotic, or coughs incessantly,
the tube is likely to be in the lungs. The nurse does not need to view the posterior
pharynx.

PTS: 1 CON: Clinical Judgment | Safety

16. ANS: 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 14. Describe the process for and importance of checking placement of nasogastric and
nasointestinal tubes and checking residual gastric volume.
Page: 461
Heading: Securing the NG Tube
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment |Safety
Difficulty: Difficult
Feedback
1 This is incorrect. Small pieces of tape should be used to secure an NG tube.
2 This is incorrect. A 2-piece taping method is typically used when securing an NG tube.
3 This is correct. The patient’s nares should not be partially blocked when securing the
NG tube because it can cause complications. Be certain to tape the tube so that it is
centered in the naris opening and does not press against any portion of the naris. If the
tube presses against the nose, it can cause a pressure ulcer.
4 This is incorrect. Never let go of the tube until it is secured. It can come out in the blink
of an eye, especially if the patient coughs, gags, or moves.

PTS: 1 CON: Clinical Judgment |Safety

17. ANS: 2
Chapter: Chapter 24, Nutritional Care and Support
Objective: 1. Define various terms associated with nutritional care and support.
Page: 449
Heading: Supporting Patients With Special Nutritional Needs
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Nutrition
Difficulty: Moderate
Feedback

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 1 This is incorrect. Anaphylaxis is a life-threatening emergency, which involves swelling
of the upper respiratory tract that can result in occlusion of the airway. Anaphylaxis
also causes vascular collapse.
2 This is correct. Food intolerance usually involves gastrointestinal symptoms, including
bloating, flatulence, diarrhea, and nausea.
3 This is incorrect. Typically, a patient with a food allergy will have such symptoms as
skin, respiratory, and gastrointestinal reactions that get increasingly worse with
repeated exposure to the offending agent.
4 This is incorrect. Food poisoning would cause more acute symptoms, such as cramping,
vomiting, and diarrhea.

PTS: 1 CON: Nutrition

18. ANS: 2
Chapter: Chapter 24, Nutritional Care and Support
Objective:15. Identify nursing responsibilities for patients with feeding tubes, including the prevention of
complications.
Page: 465
Heading: Intermittent Tube Feedings
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment |Nutrition
Difficulty: Difficult
Feedback
1 This is incorrect. The placement should be checked prior to initiating an intermittent
tube feeding.
2 This is correct. Following an intermittent tube feeding, the HOB should be maintained
at 30 to 40 degrees for at least 1 hour to minimize the risk for aspiration.
3 This is incorrect. The residual should be checked prior to initiating an intermittent tube
feeding.
4 This is incorrect. The patency of a feeding tube should be checked prior to initiating an
intermittent tube feeding.

PTS: 1 CON: Clinical Judgment |Nutrition

19. ANS: 4
Chapter: Chapter 24, Nutritional Care and Support
Objective: 15. Identify nursing responsibilities for patients with feeding tubes, including the prevention of
complications.
Page: 466
Heading: Checking Residual Gastric Volume
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment |Nutrition | Safety
Difficulty: Difficult
Feedback
1 This is incorrect. The nurse should verify NG tube placement using a stethoscope.
2 This is incorrect. The nurse should verify the HCP order because it has been changed
from intermittent to continuous feedings. The nurse should always check the HCP order

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 before providing care.
3 This is incorrect. Tube feedings should be at room temperature prior to administering.
4 This is correct. The nurse should always check for residual volume. The patient had
previously been receiving intermittent feedings and now the order has been changed to
continuous feedings. The nurse should follow established hospital policies related to
NG tube administration.

PTS: 1 CON: Clinical Judgment |Nutrition | Safety

20. ANS: 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 9. Describe how drugs can affect food intake, absorption, metabolism, and excretion of nutrients.
Page:456
Heading: Drug Effects on Metabolism of Nutrients
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
Concept: Clinical Judgment | Nutrition
Difficulty: Moderate

Feedback
1 This is incorrect. The patient had 2 cups of coffee (300), a large bowl of soup (240),
and half a carton of milk (120). Total would be 660 mL.
2 This is incorrect. The patient had 2 cups of coffee (300), a large bowl of soup (240),
and half a carton of milk (120). Total would be 660 mL.
3 This is correct. The patient had 2 cups of coffee (300), a large bowl of soup (240), and
half a carton of milk (120). Total would be 660 mL.
4 This is incorrect. The patient had 2 cups of coffee (300), a large bowl of soup (240),
and half a carton of milk (120). Total would be 660 mL.

PTS: 1 CON: Clinical Judgment | Nutrition

MULTIPLE RESPONSE

21. ANS: 2, 3, 4, 5
Chapter: Chapter 24, Nutritional Care and Support
Objective: 8. Identify common eating disorders.
Page: 454-455
Heading: Anorexia Nervosa
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Clinical Judgment | Nutrition
Difficulty: Moderate

Feedback
1 This is incorrect. Gastric reflux is an expected finding in anorexia nervosa patients.
2 This is correct. Menstrual irregularities resulting in amenorrhea are common findings in
female anorexia nervosa patients.
3 This is correct. Decreased skin turgor is indicative of dehydration, which is a common

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 finding in anorexia nervosa patients.
4 This is correct. Muscle wasting is a common finding in anorexia nervosa patients.
5 This is correct. Decreased grip strength is a common finding in anorexia nervosa
patients.

PTS: 1 CON: Clinical Judgment | Nutrition

22. ANS: 1, 2, 4, 5
Chapter: Chapter 24, Nutritional Care and Support
Objective: 8. Identify common eating disorders.
Page: 455
Heading: Binge Eating Disorder
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment | Nutrition
Difficulty: Difficult

Feedback
1 This is correct. No purging is associated with binge eating disorders.
2 This is correct. Binge eating disorders are seen in patients who are overweight or obese
as reflected in BMIs 25 and higher.
3 This is incorrect. Binge eating disorders are seen more in females than in males.
4 This is correct. Psychological attributes (feelings of shame, distress, and guilt)
accompany binges and are present after the binges.
5 This is correct. Binge eating disorder is considered to be a treatable condition.

PTS: 1 CON: Clinical Judgment |Nutrition

23. ANS: 1, 2, 3
Chapter: Chapter 24, Nutritional Care and Support
Objective: 6. Describe the nurse’s responsibilities for patients on special diets, including diabetics and their
specific needs.
Page: 450
Heading: Diets Modified by Consistency
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment | Nutrition
Difficulty: Difficult

Feedback
1 This is correct. A major factor that indicates to the nurse that a clear liquid diet should
not be advanced is hypoactive bowel sounds.
2 This is correct. If the patient has nausea and vomiting, the clear liquid diet is not being
tolerated and should not be advanced.
3 This is correct. The presence of indigestion is an indicator that the clear liquid diet is
not being well tolerated; the diet should not be advanced.
4 This is incorrect. Hunger alone is not an appropriate reason to advance a patient’s diet.
Hunger does not indicate the level of tolerance for the current diet.
5 This is incorrect. The patient on a clear liquid diet does not have a reason to be thirsty.

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 Water and other clear liquids can be provided to the patient when requested.

PTS: 1 CON: Clinical Judgment |Nutrition

24. ANS: 1, 3, 4, 5
Chapter: Chapter 24, Nutritional Care and Support
Objective: 6. Describe the nurse’s responsibilities for patients on special diets, including diabetics and their
specific needs.
Page: 462
Heading: Nursing Responsibilities for an NG Tube Connected to Suction
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Clinical Judgment |Nutrition
Difficulty: Moderate

Feedback
1 This is correct. Assess tubing connections to prevent accidental disconnection.
2 This is incorrect. The patient may have ice chips but typically PO fluids are not given to
a patient who has a NG tube to continuous suction.
3 This is correct. The nurse should auscultate bowel sounds every 4 hours, noting
hyperactive, hypoactive, and absent sounds.
4 This is correct. The nurse should provide mouth care and apply lip moisturizer every 2
hours to prevent drying of the mucous membranes.
5 This is correct. The nurse should monitor and document I&O for a patient with an NG
tube on continuous suction.

PTS: 1 CON: Clinical Judgment |Nutrition

25. ANS: 3, 4, 5
Chapter: Chapter 24, Nutritional Care and Support
Objective: 6. Describe the nurse’s responsibilities for patients on special diets, including diabetics and their
specific needs.
Page: 450
Heading: Diets Modified by Consistency
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Clinical Judgment | Nutrition
Difficulty: Difficult

Feedback
1 This is incorrect. The Infusion Nurses Society states that peripherally administered PPN
solution cannot contain a concentration that exceeds 10% dextrose and 5% amino acids.
2 This is incorrect. PPN solutions are either isotonic or mildly hypertonic to prevent
phlebitis and decrease the risk of thrombus.
3 This is correct. The Infusion Nurses Society states that peripherally administered PPN
solution cannot contain a concentration that exceeds 10% dextrose and 5% amino acids.
4 This is correct. PPN solutions have limited calories.

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 5 This is correct. PPN include a mixture of dextrose, amino acids, lipid emulsions,
electrolytes, vitamins, and trace minerals in sterile water.

PTS: 1 CON: Clinical Judgment |Nutrition

COMPLETION

26. ANS:
gastric decompression

Rationale: Gastric decompression is the process of reducing the pressure within the stomach by emptying it of
its contents, which includes ingested food and liquids, gastric juices, and gas. The stomach contents are
removed by inserting a double-lumen NG tube through the nose into the stomach, then connecting the
drainage lumen to a suction source.

Chapter: Chapter 24, Nutritional Care and Support

Objective: 1. Define various terms associated with nutritional care and support.
Page: 459
Heading: Gastric Decompression
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Clinical Judgment
Difficulty: Moderate

PTS: 1 CON: Clinical Judgment

27. ANS:
enteral

Rationale: Enteral feedings are ordered to provide the patient with nutritional support in the form of liquid
formulas that meet the patient’s energy needs.

Chapter: Chapter 24, Nutritional Care and Support

Objective: 1. Define various terms associated with nutritional care and support.
Page: 462
Heading: Enteral Nutrition
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
Concept: Clinical Judgment | Nutrition
Difficulty: Moderate

PTS: 1 CON: Clinical Judgment |Nutrition

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