Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is calculating the protein needs of a client who is a physical trainer.
The client weighs 220 lb and requires an increase of protein by 2.0 g/kg/day.
The client has taken 0.8 g of protein/kg/day in the past.
How much total protein/day should the nurse recommend?
A. 80 g of protein/day.
This choice suggests that the client needs 80 g of protein/day. However, this is not correct because the client’s weight is 220 lb (which is approximately 100 kg), and they require an increase of protein by 2.0 g/kg/day. This means they need an additional 200 g of protein per day. Adding this to their past intake of 0.8 g/kg/day (which is 80 g/day), the total comes to 280 g/day.
B. 120 g of protein/day.
This choice suggests that the client needs 120 g of protein/day. The client’s total protein requirement per day is more than this.
C. 280 g of protein/day.
Given: - The client's weight is 220 lb. - The client requires an increase of protein by 2.0 g/kg/day. - The client has taken 0.8 g of protein/kg/day in the past. We know that 1 kg = 2.2 lbs. So, we first need to convert the client's weight from lbs to kg. Step 1: Convert the client's weight from lbs to kg 220 lb ÷ 2.2 lb/kg = 100 kg Next, we calculate the increased protein requirement. Step 2: Calculate the increased protein requirement 100 kg × 2.0 g/kg/day = 200 g/day Then, we calculate the past protein intake in g/day. Step 3: Calculate the past protein intake 100 kg × 0.8 g/kg/day = 80 g/day Finally, we add the past protein intake to the increased protein requirement to get the total protein/day the nurse should recommend. Step 4: Calculate the total protein/day 200 g/day + 80 g/day = 280 g/day
D. 400 g of protein/day.
This choice suggests that the client needs 400 g of protein/day. However, this is not correct because it exceeds the client’s total protein requirement per day, which is 280 g/day.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom T1 PM Summer 2023 Proctored Exam 5. Take the full exam now
Full Explanation
The correct answer is © 280 g of protein/day.
Choice A reason: This choice suggests that the client needs 80 g of protein/day. However, this is not correct because the client’s weight is 220 lb (which is approximately 100 kg), and they require an increase of protein by 2.0 g/kg/day. This means they need an additional 200 g of protein per day. Adding this to their past intake of 0.8 g/kg/day (which is 80 g/day), the total comes to 280 g/day.
Choice B reason: This choice suggests that the client needs 120 g of protein/day. The client’s total protein requirement per day is more than this.
Choice C reason:
Given:
- The client's weight is 220 lb.
- The client requires an increase of protein by 2.0 g/kg/day.
- The client has taken 0.8 g of protein/kg/day in the past.
We know that 1 kg = 2.2 lbs. So, we first need to convert the client's weight from lbs to kg.
Step 1: Convert the client's weight from lbs to kg
220 lb ÷ 2.2 lb/kg = 100 kg
Next, we calculate the increased protein requirement.
Step 2: Calculate the increased protein requirement
100 kg × 2.0 g/kg/day = 200 g/day
Then, we calculate the past protein intake in g/day.
Step 3: Calculate the past protein intake
100 kg × 0.8 g/kg/day = 80 g/day
Finally, we add the past protein intake to the increased protein requirement to get the total protein/day the nurse should recommend.
Step 4: Calculate the total protein/day
200 g/day + 80 g/day = 280 g/day
Choice D reason: This choice suggests that the client needs 400 g of protein/day. However, this is not correct because it exceeds the client’s total protein requirement per day, which is 280 g/day.
Similar Questions
A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis.
Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?
A. Implement a turning schedule every 4 hr.
Implement a turning schedule every 4 hr. Rationale: Turning schedules are essential for preventing skin breakdown in clients with limited mobility, such as those with spinal cord injuries. However, the recommended turning interval is generally every 2 hours, not every 4 hours. Prolonged pressure on the skin can lead to tissue damage and pressure ulcers. Therefore, choice A is not the best option for decreasing the client's risk of skin breakdown.
B. Minimize skin exposure to moisture.
Minimize skin exposure to moisture. Rationale: Moisture can increase the risk of skin breakdown, especially in areas with skin-to-skin contact or incontinence. Keeping the skin dry is crucial in preventing pressure ulcers. Moisture can soften the skin, making it more susceptible to damage. Therefore, choice B is a vital action to include in the plan of care to decrease the client's risk of skin breakdown.
C. Massage erythematous bony prominences.
Massage erythematous bony prominences. Rationale: Massaging erythematous (red) bony prominences is contraindicated in clients at risk of pressure ulcers. This can further damage the already compromised skin and underlying tissue. It is important to avoid friction and pressure on these areas. Therefore, choice C is not appropriate for preventing skin breakdown.
D. Keep environmental humidity less than 30%.
Keep environmental humidity less than 30%. Rationale: Environmental humidity levels do not significantly impact the risk of skin breakdown in clients with spinal cord injuries. Maintaining appropriate humidity levels is important for general comfort and respiratory health, but it does not directly address the prevention of pressure ulcers. Therefore, choice D is not the best action for this purpose.
E. Use pillows to keep heels off the bed surface.
Use pillows to keep heels off the bed surface. Rationale: Elevating the heels with pillows is an effective preventive measure to reduce pressure on the heels, which are common sites for pressure ulcers in immobile clients. This action helps to distribute pressure more evenly and reduces the risk of skin breakdown. Therefore, choice E is a suitable action to include in the plan of care to decrease the client's risk of skin breakdown.
A nurse is assisting with the food tray for a client who is partially blind following a left-sided stroke.
Which of the following nursing interventions promotes client independence?
A. Explain that the tray is here and place the client's hands on the tray.
Explaining that the tray is here and placing the client’s hands on the tray is a supportive action but does not promote independence. It may help the client initially find the tray, but it doesn’t guide them in understanding where each item of food is located, which is essential for independent feeding.
B. Assign an assistive personnel to feed the client.
Assigning assistive personnel to feed the client would provide support but would not promote independence. It could lead to increased dependence on others for feeding and may reduce the client’s motivation to perform self-feeding.
C. Ask the client if she would prefer a liquid diet.
Asking the client if they would prefer a liquid diet is an important consideration for clients with swallowing difficulties, which can be a complication of a stroke. However, this does not directly promote independence in feeding if the client is capable of eating solid foods.
D. Describe to the client the location of the food on the tray.
Describing the location of the food on the tray helps the client understand where each item is placed, akin to a clock face orientation. This empowers the client to feed themselves independently, which is crucial for self-esteem and rehabilitation progress.
Full Explanation
The correct answer is D.
Choice A reason: Explaining that the tray is here and placing the client’s hands on the tray is a supportive action but does not promote independence. It may help the client initially find the tray, but it doesn’t guide them in understanding where each item of food is located, which is essential for independent feeding.
Choice B reason: Assigning assistive personnel to feed the client would provide support but would not promote independence. It could lead to increased dependence on others for feeding and may reduce the client’s motivation to perform self-feeding.
Choice C reason: Asking the client if they would prefer a liquid diet is an important consideration for clients with swallowing difficulties, which can be a complication of a stroke. However, this does not directly promote independence in feeding if the client is capable of eating solid foods.
Choice D reason: Describing the location of the food on the tray helps the client understand where each item is placed, akin to a clock face orientation. This empowers the client to feed themselves independently, which is crucial for self-esteem and rehabilitation progress.
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis.
Which of the following actions is the nurse's priority?
A. Document intake and output.
Document intake and output. Rationale: Documenting intake and output is an important aspect of nursing care, but it is not the top priority when a child has a suspected diagnosis of bacterial meningitis. Immediate interventions to address the underlying condition and prevent complications take precedence.
B. Administer antibiotics when available.
Administer antibiotics when available. Rationale: Administering antibiotics is the nurse's top priority when a child has a suspected diagnosis of bacterial meningitis. Timely antibiotic therapy is crucial to treat the infection and prevent its progression. Delaying antibiotic administration can lead to severe complications, including neurological damage and death.
C. Maintain seizure precautions.
Maintain seizure precautions. Rationale: Maintaining seizure precautions is important for clients with neurological conditions, including meningitis. However, it is not the nurse's top priority when bacterial meningitis is suspected. Immediate treatment with antibiotics takes precedence over seizure precautions.
D. Reduce environmental stimuli.
Reduce environmental stimuli. Rationale: Reducing environmental stimuli is a consideration in the care of clients with neurological conditions to prevent agitation and seizures. However, it is not the nurse's top priority when a child has a suspected diagnosis of bacterial meningitis. The primary focus should be on administering antibiotics promptly to address the infection.