Nutrition And Hydration - NCLEX Rn

Identify the total intake in mL: $240$ mL juice + $180$ mL soup + $120$ mL water.

$540$ mL. Represents the cumulative volume of all consumed fluids for accurate intake monitoring.
Which electrolyte imbalance is most associated with peaked T waves on ECG?

Hyperkalemia. Elevated potassium alters cardiac conduction, producing distinctive ECG changes.
Identify the best indicator of adequate enteral feeding tolerance.

Absence of nausea, vomiting, abdominal distention, and diarrhea. Demonstrates gastrointestinal tolerance without signs of malabsorption or distress.
Which finding is most consistent with fluid volume deficit?

Tachycardia. Compensatory mechanism to maintain cardiac output amid reduced circulating volume.
What is the formula to calculate IV flow rate in mL/hr from volume and time?

$\text{mL/hr} = \frac{\text{mL}}{\text{hr}}$ . Divides total infusion volume by duration to determine the hourly administration rate.
Which diet consistency is typically recommended for dysphagia to reduce aspiration?

Thickened liquids and texture-modified foods as ordered. Thicker consistencies slow bolus transit, allowing better control and reducing aspiration risk.
Which electrolyte is most critical to monitor for refeeding syndrome complications?

Phosphorus. Hypophosphatemia is a hallmark due to insulin-driven intracellular shifts during refeeding.
Which electrolyte imbalance is most associated with muscle weakness and dysrhythmias?

Hypokalemia. Low potassium impairs neuromuscular function and cardiac repolarization.
Which diet is most appropriate for a client with heart failure and fluid retention?

Low-sodium diet. Reduces sodium-induced fluid retention, alleviating cardiac strain and edema.
Which client position is safest during oral feeding to reduce aspiration risk?

High-Fowler position (upright at $90^\circ$ ). Promotes gravity-assisted swallowing and minimizes the risk of food or liquid entering the airway.
What is the priority nursing assessment to detect dehydration in an older adult?

Orthostatic vital signs (postural hypotension). Detects volume depletion through blood pressure drop upon position change due to reduced preload.
Which nutrient deficiency is classically associated with rickets/osteomalacia?

Vitamin D deficiency. Impairs calcium and phosphate metabolism, resulting in defective bone mineralization.
Which route is preferred for nutrition support when the gastrointestinal tract is functional?

Enteral feeding. Preserves gut mucosa, reduces translocation risks, and is more cost-effective than parenteral.
Which vitamin deficiency is most associated with megaloblastic anemia in pregnancy?

Folate (vitamin B9) deficiency. Essential for DNA synthesis, and lack during rapid cell division causes macrocytic anemia.
Which nutrient deficiency is classically associated with scurvy?

Vitamin C deficiency. Ascorbic acid is essential for collagen synthesis, and its absence leads to connective tissue fragility.
Which diet is most appropriate for a client with chronic kidney disease and hyperkalemia?

Low-potassium diet. Restricts potassium to compensate for reduced renal excretion in kidney dysfunction.
What is the priority intervention if a client coughs or gurgles during feeding?

Stop feeding and assess airway/swallowing immediately. These signs may indicate aspiration, requiring prompt evaluation to maintain airway patency.
What is the priority nursing action to prevent refeeding syndrome in severe malnutrition?

Initiate nutrition slowly and monitor electrolytes closely. Gradual reintroduction prevents rapid metabolic shifts and electrolyte imbalances.
What is the most appropriate nursing action before feeding a client with dysphagia?

Perform a swallow screening/assessment before oral intake. Ensures safe swallowing to prevent aspiration pneumonia in clients with impaired deglutition.
Which finding is most consistent with fluid volume excess?

Crackles on lung auscultation. Indicates pulmonary edema from fluid overload, as excess volume fills alveolar spaces.
Which vitamin deficiency is most associated with night blindness?

Vitamin A deficiency. Retinol is vital for visual pigment formation, and deficiency impairs low-light adaptation.
What is the expected urine output goal for adequate adult renal perfusion?

At least $30$ mL/hr. Reflects adequate glomerular filtration rate and hydration status in adults.
What is the priority dietary teaching for a client on warfarin therapy?

Maintain consistent vitamin K intake (do not vary day to day). Consistency stabilizes INR by avoiding fluctuations in vitamin K antagonism of warfarin.
Identify the IV pump rate for $1000$ mL to infuse over $8$ hours.

$125$ mL/hr. Derived from dividing total volume by infusion time for accurate pump programming.
Which laboratory value is the most direct indicator of long-term glycemic control?

Hemoglobin A1c. Reflects average blood glucose over 2-3 months via glycated hemoglobin percentage.

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