1. A nurse responds to the cardiac monitor alarm of a patient and observes that the patient has atrial flutter. The patient is sitting up in the bed and is responsive. Which of the following actions should the nurse take first? a. Institute carotid sinus massage b. Assess the patient for dyspnea c. Initiate CPR d. Place the patient Trendelenburg position 2. The night after an exploratory laparotomy, a patient who has a nasogastric tube attached to low suction reports nausea. A nurse should take which of the following action first? a. Administer antiemetic medication b. Determine the patency of the patient’s NG tube c. Instruct the patient to take deep breaths d. Asses the patient’s pain level 3. A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse?  a. a client with a cast for a fractured femur and who has numbness and discoloration of the toes b. a client with balanced skeletal traction and who needs assistance with morning care c. a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F degrees d. a client who had a total hip replacement 2 days ago and needs blood glucose 4. A nurse is caring for four clients and is preparing to do her initial rounds. Which client should the nurse assess first? a. A patient with diabetes being discharged today b. A patient with a trach with lots of secretions c. A patient scheduled for PT this morning d. A patient with a pressure ulcer that needs a dressing change 5. A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first?  a. Call for help b. Determine if the patient is responsive c. Assist the patient back to bed d. Ask the patient what happened 6. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse make first?  a. Respiratory status b. Level of consciousness c. Level of pain d. Reflexes and movement of extremities 7. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. Which is a priority for the nurse to counsel the client to avoid in her diet?  a. Fiber b. Yogurt c. Broccoli d. Simple carbs 8. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first?  a. Sit the patient in the activity chair b. Apply a vest restraint c. Apply wrist restraints in the bed d. Have a staff member sit with the patient for the entire shift 9. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first?  a. Start an IV b. Administer oxygen c. Administer morphine d. Start a lidocaine IV drip 10. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that.

1. 1. A nurse responds to the cardiac monitor alarm of a patient
and observes that the patient has atrial flutter. The patient is
sitting up in the bed and is responsive. Which of the following
actions should the nurse take first?
a. Institute carotid sinus massage
b. Assess the patient for dyspnea
c. Initiate CPR
d. Place the patient Trendelenburg position
2. The night after an exploratory laparotomy, a patient who has
a nasogastric tube attached to low suction reports nausea. A
nurse should take which of the following action first?
a. Administer antiemetic medication
b. Determine the patency of the patient’s NG tube
c. Instruct the patient to take deep breaths
d. Asses the patient’s pain level
3. A nurse from medical-surgical unit is asked to work on the
orthopedic unit. The medical-surgical nurse has no orthopedic
nursing experience. Which client should be assigned to the
medical-surgical nurse?
a. a client with a cast for a fractured femur and who has
numbness and discoloration of the toes
b. a client with balanced skeletal traction and who needs
assistance with morning care
c. a client who had an above-the-knee amputation yesterday and
has a temperature of 101.4F degrees
d. a client who had a total hip replacement 2 days ago and needs
blood glucose
4. A nurse is caring for four clients and is preparing to do her
initial rounds. Which client should the nurse assess first?
a. A patient with diabetes being discharged today

2. b. A patient with a trach with lots of secretions
c. A patient scheduled for PT this morning
d. A patient with a pressure ulcer that needs a dressing change
5. A nurse enters a room and finds a client lying on the floor.
Which action should the nurse perform first?
a. Call for help
b. Determine if the patient is responsive
c. Assist the patient back to bed
d. Ask the patient what happened
6. The nurse plans care for a client in the post-anesthesia care
unit. Which assessment should the nurse make first?
a. Respiratory status
b. Level of consciousness
c. Level of pain
d. Reflexes and movement of extremities
7. A nurse in the clinic is reviewing the diet of a 28-year old
female who reports several months of intermittent abdominal
pain, abdominal bloating, and flatulence. Which is a priority for
the nurse to counsel the client to avoid in her diet?
a. Fiber
b. Yogurt
c. Broccoli
d. Simple carbs
8. A nurse in a long term facility is planning care for an elderly
client with confusion. Which action should the nurse take first?
a. Sit the patient in the activity chair
b. Apply a vest restraint
c. Apply wrist restraints in the bed
d. Have a staff member sit with the patient for the entire shift
9. The nurse is providing care in the emergency department to
the client with chest pain. Which action is most important for

3. the nurse to do first?
a. Start an IV
b. Administer oxygen
c. Administer morphine
d. Start a lidocaine IV drip
10. A nurse arrives on the scene of a multi-motor vehicle
accident. The nurse determines that which of the following
clients should be seen first?
a. A 48 year old male who is pale, diaphoretic and reporting
chest pain and shortness of breath
b. a 16 year old male with ecchymosis, pain, and swelling of the
right arm
c. a 42 year old female who has a laceration on the forehead and
is reporting neck and shoulder pain
d. an 8 year old child who is crying and reports abdominal pain
11. A nurse is working on a poison control hot-line and gets a
call from a mother who reports her child has apparently taken
part of a bottle of adult acetaminophen capsules. The priority
action for the nurse to take first is:
a. tell the mother to position the child lying down on her side
b. tell the mother to dial 911 and request an ambulance
c. have the mother give the child a glass of milk
d. Instruct the mother how to make the child throw up
12. A nurse on the cardiac unit is caring for four clients and is
preparing to do initial rounds. Which client should the nurse
assess first?
a. Patient scheduled for cardiac ultrasound
b. A patient with syncope being discharged today
c. A patient with chronic bronchitis on nasal cannula
d. A patient with a foot ulcer with a dressing change due
13. A nurse enters a room and finds lying face down on the
floor, bleeding from a gash in the head. Which action should the
nurse perform first?

4. a. Determine level of consciousness
b. Push call bell for help
c. Turn patient to assess
d. Go out in the hall for help
14. A nurse is working on the night shift with a nursing
assistant. The nursing assistant comes to the nurse stating that
the other nurse working on the unit is not assessing a client with
abdominal pain despite multiple requests. Which of the
following actions by the nurse is best?
a. Ask the other nurse if she needs help
b. Assess the patient and let the other nurse know what to do
c. Ask the patient if he is satisfied with his care
d. Contact the nursing supervisor to address the situation
15. The nurse is reviewing immunizations with the caregiver of
a 72 year old client with a history of cerebral vascular disease.
The caregiver learns that which immunization is a priority for
the client?
a. Hepatitis A vaccine
b. Lyme disease vaccine
c. Hepatitis B vaccine
d. Pneumococcal vaccine
Nutrition Handout
Please answer all questions in your own words. No citations are
needed for this assignment as the answers are located in your
textbook. Please ensure your answers are brief so they will fit
inside each box.
1. Please complete the following table.
Nutrient
Function and deficiency
Sources
Carbohydrates

5. Fiber
Proteins
Fats
Fat-soluble vitamins
A,D,E, K
Water-soluble vitamins
B and C complex
2. Identify the diagnostic criteria for the following eating
disorders:
Anorexia nervosa
Bulimia nervosa
3. What is an enteral feeding?

6. 4. What are three benefits of enteral feedings?
1
2
3
5. Identify five complications of enteral tube feedings and a
possible cause for each
1
2
3
4
5
6. What is parenteral feeding?
7. What are three benefits of parenteral feedings?
1
2
3

7. 8. Identify five complications of parenteral tube feedings and a
symptom of each complication
1
2
3
4
5
9. Please complete the table below
Condition
Description
Nutritional interventions
Helicobacter pylori
Malabsorption syndromes
Diverticulitis
Diabetes mellitus
Inflammatory bowel disease
10. What is dysphagia?

8. 11. Please list the four levels of the dysphagia diet
1
2
3
4
12. List the five components of a nutritional assessment and
briefly explain each
1
2
3
4
5
13. Please complete the table below
Assessment area
One sign of poor nutrition
Posture
Gums
Tongue
Teeth

9. Legs, feet
Nails
Hair
Weight
Gastrointestinal function
Muscles
14. Identify three factors that contribute to childhood obesity.
Use table below.
1
2
3
15. Identify three factors that influence an adolescent’s diet.
1
2
3
16. Identify three factors that influence the nutritional status of
the older adult.
1
2

10. 3
17. Give one nursing diagnosis for a patient with altered
nutritional status.
18. Give two goals for a client with nutritional problems.
19. What is aspiration? List two aspiration precautions you
should utilize for patients at risk.
20. Explain the goal of transition from parenteral nutrition to
enteral nutrition.
21. Explain the goal of transition from parenteral nutrition to
oral feeding.
22. Describe lipid emulsions and how it benefits patients with
altered nutritional status.
23. What is medical nutrition therapy?
24. Which nutrition is the body’s most preferred energy
source?
A. Carbohydrate
B. Fat
C. Protein
D. Vitamin
25. Mrs. Nelson is talking with the nurse about the dietary
needs of her 22-month-old son. Which of the following
responses by the nurse would be appropriate?
A. Your son needs fewer calories in relation to her body weight
now than she did as an infant.
B. Your son needs less protein in his diet now because he is not
growing as fast.

11. C. Your son should be drinking at least one quart of milk per
day.
D. Use skim milk to cut down on the fat in your son’s diet.
26. All of the following clients are at risk for alteration in
nutrition except:
A. Client A, who has been allowed nothing by mouth (NPO) for
seven days following bowel surgery and is receiving 3000ml of
10% dextrose per day.
B. Client B, a 17-year-old girl who weighs 90 pounds and
frequently complains about her baby fat.
C. Client C, who is 86 years old, lives alone, and has poorly
fitting dentures.
D. Client D, whose weight is 10% above his ideal body weight.
27. Which of the following is the most accurate method of
bedside confirmation of placement of a small-bore nasogastric
tube?
A. Assess the client’s ability to speak.
B. Test the pH of withdrawn gastric contents.
C. Auscultate the epigastrium for gurgling or bubbling.
D. Assess the length of the tube that is outside the client’s nose.