Nutrition And Hydration - NCLEX Rn

1. A 9-year-old child with type 1 diabetes is admitted for gastroenteritis with vomiting. The child is lethargic with dry mucous membranes; vital signs: HR 124/min, BP 90/56 mm Hg. Labs: glucose 280 mg/dL, Na 150 mEq/L. What is the PRIORITY nursing intervention for this client's hydration status?
   Answer: Initiate IV isotonic fluids per protocol or provider order and monitor blood glucose and urine output closely This question tests clinical judgment in nutrition and hydration management. The priority concern is dehydration exacerbating hyperglycemia in diabetes, indicated by lethargy, dry membranes, tachycardia, hypotension, high glucose, and hypernatremia. Initiating IV isotonic fluids while monitoring glucose and output is the highest priority to prevent DKA and restore volume. Holding fluids, delegating juice, or obtaining a food diary are incorrect as they risk worsening or delay urgent care. This applies the principle of prioritizing ABCs and metabolic stability in pediatric diabetes. A transferable strategy is to use IV fluids and insulin protocols for dehydrated diabetic children, tracking labs closely for resolution.
2. An 82-year-old client takes furosemide for hypertension and reports "not drinking much" to avoid frequent urination. Assessment shows dry mucous membranes and dizziness; vital signs: HR 96/min, BP 104/62 mm Hg. Labs: K 3.0 mEq/L, Na 146 mEq/L. What is the PRIORITY nursing intervention for this client's hydration status?
   Answer: Encourage oral fluids and notify the provider of hypokalemia and possible volume depletion for medication and fluid plan adjustments This question tests clinical judgment in nutrition and hydration management. The priority concern is dehydration and hypokalemia from diuretic use and low intake, evidenced by dry membranes, dizziness, tachycardia, low blood pressure, and labs. Encouraging oral fluids and notifying the provider is the highest priority to correct deficits and adjust the care plan safely. Holding medications or administering potassium without orders, delegating ambulation, or providing low-sodium education are incorrect as they violate scope or overlook urgency. This applies the principle of prioritizing notification and safe interventions for medication-related imbalances. A transferable strategy is to assess fluid-electrolyte status in diuretic users and promote hydration while seeking orders for adjustments.
3. A 16-year-old client with lactose intolerance is admitted for a sports-related fracture and reports avoiding "all dairy". The client has had minimal intake in the hospital and complains of fatigue. Labs: calcium 8.3 mg/dL. Which dietary modification should the nurse implement IMMEDIATELY?
   Answer: Offer lactose-free calcium and vitamin D sources (e.g., fortified plant milk, lactose-free yogurt) with meals This question tests clinical judgment in nutrition and hydration management. The priority concern is hypocalcemia from dairy avoidance in lactose intolerance, indicated by low calcium levels and fatigue. Offering lactose-free calcium sources is the highest priority to meet nutritional needs without GI distress. Encouraging whole milk, restricting calcium, or delegating teaching are incorrect as they could cause symptoms or neglect education. This applies the principle of adapting diets to intolerances while ensuring nutrient balance. A transferable strategy is to recommend alternative sources and supplements for key nutrients in clients with food restrictions, monitoring labs for deficiencies.
4. A 74-year-old client is receiving enteral feedings via NG tube after a stroke. The client has crackles at the right base and a new cough; gastric residual volume is 350 mL. Vital signs: T 37.9°C (100.2°F), RR 22/min. Which action should the nurse take FIRST to address the client's nutritional needs?
   Answer: Stop the feeding, elevate the head of bed, and assess for aspiration before resuming or notifying the provider. The crackles, new cough, fever, and high residual volume all suggest aspiration in an NG-fed client, so the first action is to protect the airway: stop the feeding, elevate the head of bed, and assess for aspiration before resuming the feeding or notifying the provider. This is the only option that halts the ongoing risk. The option that documents and leaves the current ordered feeding running while rechecking later delays the assessment and keeps delivering formula. The option that increases the feeding rate, even with the head of bed at 45 degrees, prioritizes caloric goals over airway safety and can worsen aspiration. The option that delegates a flush and continues the current feeding still leaves the aspiration risk active and fails to provide the nurse's own assessment. After assessment, the provider should be notified and feeding resumed only when safe.
5. A 58-year-old client with type 2 diabetes is admitted for an infected foot ulcer. The client reports poor appetite and "skipping meals." Assessment: weight loss of 4.5 kg (10 lb) over 2 months, albumin 2.9 g/dL, prealbumin 14 mg/dL, fasting glucose 210 mg/dL. The client is prescribed a consistent-carbohydrate diet. Which action should the nurse take FIRST to address the client's nutritional needs to promote wound healing?
   Answer: Encourage the client to eat high-protein foods with each meal and offer a protein supplement as ordered This question tests clinical judgment in managing malnutrition in a diabetic client with poor wound healing. The client presents with protein-energy malnutrition evidenced by significant weight loss (10 lb/2 months), low albumin (2.9 g/dL), and low prealbumin (14 mg/dL), which directly impairs wound healing and immune function. Option A is correct because encouraging high-protein foods and supplements addresses the immediate need for adequate protein to support wound healing while maintaining the consistent-carbohydrate approach for diabetes management. Option B is dangerous as holding all carbohydrates could cause hypoglycemia and further compromise nutritional status; Option C delays necessary intervention when malnutrition is already evident; Option D doesn't address the specific need for increased protein intake. The clinical principle is prioritizing adequate protein intake for wound healing while maintaining glycemic control through consistent carbohydrate intake rather than restriction. In diabetic clients with wounds, focus on increasing protein intake to 1.2-1.5 g/kg/day, maintain consistent carbohydrate intake with each meal, and monitor both nutritional markers and glucose levels to optimize healing.
6. A 6-year-old child with celiac disease is hospitalized for dehydration after 2 days of vomiting. The parent reports the child "usually eats gluten-free" but is requesting crackers and regular pasta. Assessment: weight down 1.0 kg from baseline, dry lips, capillary refill 3 seconds, HR 124/min, BP 96/58 mm Hg. Labs: sodium 134 mEq/L, potassium 3.4 mEq/L. Which dietary modification should the nurse implement IMMEDIATELY?
   Answer: Provide gluten-free oral rehydration solution in small, frequent sips as tolerated This question tests clinical judgment in managing dehydration in a child with celiac disease requiring strict dietary restrictions. The child presents with moderate dehydration (weight loss 1.0 kg, dry lips, delayed capillary refill, tachycardia) and mild hyponatremia (134 mEq/L), requiring immediate rehydration while maintaining gluten-free status to prevent further intestinal damage. Option A is correct because providing gluten-free oral rehydration solution addresses both the immediate hydration needs and maintains the required dietary restriction, with small frequent sips reducing risk of further vomiting. Option B would worsen the celiac disease by introducing gluten and could trigger more severe symptoms; Option C addresses long-term management but not immediate dehydration; Option D delays necessary intervention and teaching is not the priority during acute illness. The clinical principle is maintaining disease-specific dietary restrictions even during acute treatment while addressing the immediate hydration deficit. When managing children with celiac disease, always ensure all foods and fluids are certified gluten-free, use oral rehydration when tolerated, and educate families about hidden gluten sources to prevent accidental exposure.
7. A 40-year-old client is 24 hours post-operative after a total abdominal hysterectomy. The client reports nausea and has eaten less than 25% of meals; urine output is 25 mL/hr for the last 4 hours. Vital signs: HR 110/min, BP 94/60 mm Hg. What is the PRIORITY nursing intervention for this client's hydration status?
   Answer: Administer prescribed antiemetic and encourage oral fluids as tolerated while assessing response This question tests clinical judgment in nutrition and hydration management. The priority concern is post-operative dehydration risk from nausea and low intake, shown by low urine output, tachycardia, and hypotension. Administering an antiemetic and encouraging oral fluids is the highest priority to alleviate symptoms and improve hydration. Requesting TPN, delegating snacks, or obtaining a calorie count are lower priority without first managing nausea. This applies the principle of prioritizing symptom control to facilitate nutrition in early post-op recovery. A transferable strategy is to address barriers like nausea promptly with medications before advancing intake in surgical clients.
8. A 58-year-old client with type 2 diabetes is hospitalized for a foot infection and has poor wound healing. The client reports eating mostly "juice and toast" due to low appetite; weight is down 4 kg in 2 months. Labs: albumin 2.9 g/dL, glucose 220 mg/dL. Which action should the nurse take FIRST to address the client's nutritional needs?
   Answer: Collaborate with the provider and dietitian to initiate a consistent-carbohydrate, high-protein meal plan to support wound healing This question tests clinical judgment in nutrition and hydration management. The priority concern is malnutrition impairing wound healing in diabetes, shown by weight loss, low albumin, and hyperglycemia. Collaborating for a consistent-carbohydrate, high-protein meal plan is the highest priority to stabilize glucose and support tissue repair. Encouraging fruit juice, delegating documentation, or asking about preferences are lower priority without addressing core needs first. This applies the principle of interprofessional collaboration for tailored nutrition in chronic illness. A transferable strategy is to integrate glycemic control with protein enhancement in diabetic clients with wounds, monitoring labs for improvement.
9. A 68-year-old client is post-operative day 2 after hip surgery and is receiving opioids for pain. The client reports constipation and poor appetite; intake has been <800 mL/day. Labs: Na 145 mEq/L, BUN 28 mg/dL. Which action should the nurse take FIRST to address the client's nutritional needs?
   Answer: Encourage increased oral fluids and fiber as tolerated and promote early ambulation to support bowel function This question tests clinical judgment in nutrition and hydration management. The priority concern is constipation and poor intake from opioids and low fluid/fiber, indicated by symptoms and mild dehydration labs. Encouraging fluids, fiber, and ambulation is the highest priority to promote bowel motility and hydration. Keeping NPO, delegating laxatives without assessment, or requesting PN are incorrect as they could worsen issues or are unnecessary. This applies the principle of non-pharmacologic interventions first for post-op complications. A transferable strategy is to integrate mobility and dietary fiber with hydration to prevent constipation in immobilized clients on opioids.
10. A 3-month-old infant is brought to the clinic with 1 day of diarrhea. The parent reports fewer wet diapers and difficulty feeding. Assessment: sunken anterior fontanel, dry mucous membranes, capillary refill 4 seconds, HR 168/min, weight decreased from 6.2 kg to 5.8 kg. What is the PRIORITY nursing intervention for this client's hydration status?
    Answer: Initiate oral rehydration solution in small, frequent amounts and monitor for continued signs of dehydration This infant has moderate dehydration: weight dropped from 6.2 kg to 5.8 kg (>5% loss), with sunken fontanel, dry mucosa, delayed capillary refill, and tachycardia. The priority is to correct the fluid deficit promptly, so initiating oral rehydration solution in small, frequent amounts is best; it replaces water and electrolytes, and monitoring for continued dehydration tells you whether escalation to IV therapy is needed. Diluting formula with extra water is unsafe: it provides free water without balanced electrolytes and can cause hyponatremia while also lowering caloric intake. Collecting a stool sample for culture before beginning fluid therapy delays treatment and puts the infant at risk, even though culture may be useful later. Weighing diapers and documenting output helps evaluate the response, but it does not replace fluids and is not the priority. Thus the correct intervention is the oral rehydration solution with close monitoring.
11. A 77-year-old client with dysphagia after a stroke is eating less than 50% of meals and coughs during drinking. Weight decreased 2 kg in 2 weeks; lungs are clear, but the client has a wet voice after sips of water. Which action should the nurse take FIRST to address the client's nutritional needs?
    Answer: Keep the client NPO and request a swallow evaluation before offering additional oral intake The client shows classic dysphagia signs: coughing while drinking, a wet voice after sips, and weight loss. The priority is to prevent aspiration, which can cause pneumonia. Keeping the client NPO and requesting a swallow evaluation is the safest first action because it removes the risk of oral intake until swallowing is assessed. Encouraging thin liquids, even with small sips, directly increases aspiration risk and is contraindicated. Delegating feeding does not resolve the underlying swallowing deficit; it only shifts the task and may compromise safety. Providing high-calorie snacks while maintaining the same liquid consistency fails to address the dangerous aspect of liquids and delays the necessary evaluation. Therefore, the correct action is to pause oral intake and obtain a formal swallow assessment.
12. A 67-year-old client with heart failure is admitted with shortness of breath and edema. Current weight is 3 kg above baseline; lung sounds reveal crackles at bases. Labs: Na 132 mEq/L. The nurse should QUESTION which dietary order?
    Answer: Encourage 3 L/day of oral fluids to thin secretions This client is in fluid overload: weight gain, crackles, edema, and hyponatremia all point to excess volume. Your job is to spot the order that would make this worse. Encouraging 3 L/day of oral fluids would add more volume, worsening congestion and dilutional hyponatremia—so that is the order to question. The fluid restriction of 1.5 L/day is a standard approach to reduce preload and ease breathing; it fits the overload picture, so it is not the one to question. A low-sodium diet limited to 2 g/day also limits fluid retention and supports diuretics, making it appropriate care. Daily weights at the same time each morning are a monitoring tool, not a treatment order, and they help track volume trends—so they do not need to be questioned. The key is to evaluate each order against the client's fluid status: anything that adds volume is dangerous, while anything that reduces or tracks volume is appropriate.
13. A 73-year-old client is admitted with dehydration after 2 days of vomiting. Assessment: sunken eyes, dry mucous membranes, and poor skin turgor; vital signs: HR 116/min, BP 88/54 mm Hg. Labs: Na 152 mEq/L, BUN 40 mg/dL, creatinine 1.4 mg/dL. What is the PRIORITY nursing intervention for this client's hydration status?
    Answer: Start an IV and prepare to administer isotonic fluids per protocol or provider order, monitoring for improvement in perfusion This client shows signs of severe hypovolemia: tachycardia, hypotension, hypernatremia, and elevated BUN/creatinine. The priority is to rapidly expand intravascular volume with isotonic IV fluids while monitoring perfusion. Encouraging oral water is inadequate and may not be tolerated due to vomiting; obtaining a urine specific gravity is a diagnostic measure that delays treatment; dietary education does not address the acute fluid deficit. Only IV isotonic fluid administration directly corrects the volume loss and improves hemodynamic stability.
14. A 6-year-old child with celiac disease is hospitalized for poor weight gain. The parent reports frequent loose stools when the child eats "regular bread"; current weight is 18 kg, down from 19 kg one month ago. Labs: albumin 3.2 g/dL, Hgb 10.8 g/dL. Which dietary modification should the nurse implement IMMEDIATELY?
    Answer: Provide gluten-free meal selections and ensure snacks avoid wheat, barley, and rye This question tests clinical judgment in nutrition and hydration management. The priority concern is malnutrition from gluten intolerance, shown by poor weight gain, loose stools with gluten exposure, low albumin, and anemia. Providing gluten-free meal selections is the highest priority action to prevent villous atrophy and promote nutrient absorption in celiac disease. Encouraging high-fiber wheat, offering sugar-free beverages, or delegating without follow-up are incorrect as they could exacerbate symptoms or fail to ensure adherence. This applies the principle of prioritizing disease-specific dietary modifications to address immediate nutritional deficits. A transferable strategy is to educate families on allergen avoidance and monitor growth parameters in pediatric clients with dietary restrictions.
15. A 52-year-old client with newly diagnosed hypertension asks about diet changes. The client reports eating canned soups daily and has gained 1.8 kg in 1 week; mild ankle swelling is present. The nurse should QUESTION which dietary order?
    Answer: Increase canned soup intake to improve hydration This question tests clinical judgment in nutrition and hydration management. The priority concern is sodium excess contributing to hypertension and fluid retention, shown by canned soup intake, weight gain, and swelling. The nurse should question increasing canned soup as it is high in sodium, worsening symptoms. DASH diet, low-sodium, and no added salt are appropriate to control blood pressure. This applies the principle of questioning orders that contradict dietary guidelines for the condition. A transferable strategy is to educate on hidden sodium sources and promote whole foods in hypertensive clients, monitoring weight and BP for efficacy.
16. A 70-year-old client in a long-term care facility has had decreased oral intake for 3 days due to influenza. Assessment shows cracked lips, dry tongue, and orthostatic hypotension; vital signs: supine BP 118/70 mm Hg, standing BP 96/60 mm Hg, HR 112/min. Labs: Na 148 mEq/L. What is the PRIORITY nursing intervention for this client's hydration status?
    Answer: Encourage small, frequent sips of oral rehydration solution and monitor for aspiration risk The client's cracked lips, dry tongue, orthostatic hypotension, tachycardia, and hypernatremia indicate clinically significant dehydration. The priority is to begin safe, effective rehydration while protecting the airway: encourage small, frequent sips of an oral rehydration solution and monitor for aspiration. A voiding diary with reassessment in 8 hours does not replace lost fluid and delays needed correction. Ice chips, even when offered frequently and documented, provide negligible fluid and no electrolyte replacement. A multivitamin may support appetite but will not correct hypernatremia or the fluid deficit. Therefore, direct oral rehydration with aspiration monitoring is the highest-priority nursing intervention.
17. A 45-year-old client is post-operative day 1 after an open colectomy. The client is NPO with an NG tube to low suction, reports nausea, and has had 900 mL NG output in the last 12 hours; vital signs: HR 104/min, BP 100/64 mm Hg. Labs: K 3.1 mEq/L, Cl 94 mEq/L. Which action should the nurse take FIRST to address the client's nutritional needs?
    Answer: Notify the provider of the electrolyte results and anticipate potassium replacement and IV fluid adjustment. The client has had 900 mL NG output, is tachycardic with a low blood pressure, and has hypokalemia and hypochloremia. These findings indicate significant fluid and electrolyte depletion that can threaten cardiac function. The priority is to notify the provider of the electrolyte results and anticipate potassium replacement and IV fluid adjustment; this addresses the physiologic imbalance before nutrition can be safely resumed. Advancing the diet to clear liquids with antiemetics is unsafe because the client is NPO with NG suction, and oral intake cannot begin until bowel recovery and electrolyte balance are addressed. Delegating oral care and comfort measures helps maintain oral moisture but does not correct hypokalemia or provide nutrition. Obtaining a 24-hour dietary recall may be part of a later nutrition workup, but it is not the first response to acute NG losses and abnormal labs. Therefore, reporting the electrolyte values and preparing for potassium and IV fluid therapy is the only choice that addresses the immediate threat.
18. A 55-year-old client with chronic gastritis reports early satiety and has lost 6 kg over 3 months. Assessment shows muscle wasting; labs: albumin 3.0 g/dL. Which action should the nurse take FIRST to address the client's nutritional needs?
    Answer: Encourage small, frequent, nutrient-dense meals and snacks throughout the day This question tests clinical judgment in nutrition and hydration management. The priority concern is malnutrition from early satiety in gastritis, shown by weight loss, muscle wasting, and low albumin. Encouraging small, frequent, nutrient-dense meals is the highest priority to maximize intake without discomfort. Skipping breakfast, delegating without assessment, or obtaining stool samples are lower priority or unrelated to immediate nutrition. This applies the principle of optimizing meal patterns for GI conditions. A transferable strategy is to promote portion control and frequency in clients with appetite issues, tracking weight and labs for nutritional progress.
19. A 47-year-old client is post-operative after gastric surgery and reports dumping symptoms (cramping and dizziness) after meals. The client has lost 3 kg in 1 month. Which dietary modification should the nurse implement IMMEDIATELY?
    Answer: Teach the client to eat small, frequent meals and avoid drinking fluids with meals This question tests clinical judgment in nutrition and hydration management. The priority concern is dumping syndrome causing symptoms and weight loss post-gastric surgery. Teaching small, frequent meals and avoiding fluids with meals is the highest priority to slow gastric emptying and improve tolerance. Encouraging high-sugar or hot liquids, or delegating without reinforcement are incorrect as they exacerbate symptoms. This applies the principle of symptom-specific dietary education for post-surgical complications. A transferable strategy is to instruct on meal separation from fluids and monitor weight in clients with dumping syndrome.
20. An 81-year-old client with limited mobility has a stage 2 pressure injury on the sacrum. The client eats about 30% of meals and has lost 5% of body weight in 1 month; labs: albumin 2.8 g/dL. Which action should the nurse take FIRST to address the client's nutritional needs?
    Answer: Initiate high-protein, high-calorie oral nutrition supplements with meals and snacks per facility protocol This question tests clinical judgment in nutrition and hydration management. The priority concern is malnutrition delaying pressure injury healing, indicated by low intake, weight loss, and low albumin. Initiating high-protein, high-calorie supplements is the highest priority to promote tissue repair. Waiting for weights, delegating turning only, or requesting TPN first are lower priority or overlook oral options. This applies the principle of optimizing nutrition for wound healing in immobile clients. A transferable strategy is to use oral supplements as first-line for protein-calorie deficits, evaluating wound progress and labs in pressure injury cases.

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