Ch 17 Nutritional Support

5. The nurse assumes care of a patient who has been receiving intermittent enteral feedings of 240 mL of Osmolite every 4 hours for the past 48 hours. The patient is in bed with the head of the bed elevated 60 degrees. The enteral tubing is intact, and the enteral pump is infusing at 360 mL per hour. The nurse notes 60 mL of solution left in the bag. The tubing is not labeled. What will the nurse do? a. Change and label the enteral tubing when this infusion is complete. b. Increase the infusion rate to 480 mL per hour to complete the infusion. c. Lower the head of the bed to 30 degrees. d. Stop the infusion and check for residual before resuming the infusion.

ANS: A All enteral equipment should be labeled and changed every 24 hours. Since the tubing is not labeled, the nurse should change and label it as soon as the current infusion is complete. The infusion is set so that 240 mL will infuse over 45 minutes, which is appropriate, so the rate does not need to be increased. The head of the bed should be at least 30 degrees, so there is no need to lower the head of the bed. The nurse should check for residual just prior to administering the next infusion, but it is not indicated at this point. REF: Page 246

18. The nurse is caring for a patient who is being treated with total parenteral nutrition (TPN). The patient is experiencing chest pain, and the nurse observes shortness of breath and coughing along with cyanosis. The nurse understands that this patient is most likely experiencing which condition? a. Air embolism b. Pneumonia c. Pneumothorax d. Pulmonary edema

ANS: A Patients receiving TPN are at risk for air embolism and will report chest pain and be dyspneic with coughing and cyanosis. Patients with pneumonia will have cough and either adventitious breath sounds or diminished breath sounds. Patients with pneumothorax will have unilateral absent breath sounds and respiratory distress. Patients with pulmonary edema will have crackles and dyspnea. REF: Page 249

15. The nurse is caring for an adult with severe burns who weighs 60 kg. Prior to initiating total parenteral nutrition (TPN) therapy, the nurse reviews the orders. Which TPN order is correct for this patient? a. 3000 kcal, 120 g amino acids per day b. 2400 kcal, 50 g amino acids per day c. 1500 kcal, 100 g amino acids per day d. 3600 kcal, 150 g amino acids per day

ANS: A Patients should receive 30 to 60 kcal/kg/day and 1 to 2 g/kg/day of amino acids. For a 60-kg patient, the number of calories should be 1800 to 3600 kcal/day, and amino acids should be 60 to 120 g/day. REF: Page 248

7. The nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The nurse will carefully monitor this patient for which symptom(s)? a. Coughing and shortness of breath b. Decreased breath sounds c. Diarrhea d. Nausea and abdominal distension

ANS: A TPN with IV therapy is prone to air embolism. Symptoms of air embolism are coughing and dyspnea. Decreased breath sounds occur with aspiration, which is a complication of nasogastric feedings. Diarrhea, nausea, and abdominal distension occur with nasogastric feedings. REF: Page 249

2. The nurse is preparing to administer an enteral feeding to a patient who receives 300 mL of Isocal over 30 minutes every 4 hours. The nurse checks the residual prior to initiating the feeding and notes a residual amount of 50 mL of formula. Which action will the nurse take next? a. Administer the feeding as ordered. b. Administer the feeding over 60 minutes. c. Hold the feeding and notify the patient's provider. d. Wait 1 hour and recheck the residual again.

ANS: A The nurse should determine gastric residual before each feeding when patients are receiving intermittent feedings. A residual greater than 50% of a previous feeding indicates delayed gastric emptying and warrants notifying the provider. This patient has a residual less than 50%, so the nurse may proceed with the next feeding. A residual of 50 mL is significant in patients receiving continuous enteral feedings. The nurse cannot change the rate of an enteral infusion without an order from the provider. REF: Page 247

10. The nurse is preparing to administer enteral nutrition to a patient who has had a stroke and who cannot swallow. A family member asks why the patient isn't receiving intravenous nutrition. What information will the nurse provide to the family member? a. Parenteral nutrition carries a higher risk of infection. b. Parenteral nutrition does not provide sufficient calories. c. Parenteral nutrition increases the risk of aspiration. d. Parenteral nutrition is hyperosmolar and increases the risk of dehydration.

ANS: A Total parenteral nutrition (TPN) carries a greater risk of sepsis than enteral nutrition. TPN can provide sufficient calories, and there is no increased risk of aspiration with TPN. TPN does not increase the risk of dehydration. REF: Page 244

20. The nurse assumes care for a patient who is being treated with enteral feeding. When performing the initial assessment, the nurse finds the patient supine and asleep. The nurse will perform which action? a. Elevate the head of the bed 30 degrees. b. Flush the tubing with water. c. Position the patient to the left side. d. Temporarily discontinue the infusion.

ANS: A When administering an enteral feeding, the nurse should elevate the head of the patient's bed 30 degrees. REF: Page 246

4. The nurse is preparing a patient who will receive intermittent enteral nutrition at home with a hyperosmolar solution. What information will the nurse include when teaching this patient? a. How to perform the Valsalva maneuver b. The need to consume extra fluids between feedings c. The need to decrease dietary fiber d. The need to remain supine during infusion of the enteral solution

ANS: B Dehydration can occur if patients do not receive enough water during or between feedings, so patients should be taught to consume extra water. The Valsalva maneuver is taught to patients who receive TPN to prevent embolus. Enteral feedings can cause diarrhea, so decreased fiber may aggravate that. REF: Page 246

1. The nurse is preparing to administer enteral nutrition to a patient. Which assessment finding would prompt the nurse to hold the nutrition and notify the patient's provider? a. Blood pressure of 90/60 mm Hg b. Decreased bowel sounds c. A productive cough d. A temperature of 37.8° C

ANS: B Enteral nutrition requires adequate small bowel function with digestion, absorption, and gastrointestinal motility. The nurse should assess for abdominal distension and a decrease or absence of bowel sounds. Patients may still receive enteral feedings if hypotension, cough, or elevated temperature are present. REF: Page 244

3. The provider calculates the enteral nutrition needs for a nonambulatory patient and determines that the patient will need 300 mL of Ultracal every 4 hours. Which method of delivery will the nurse use to administer these feedings? a. 300 mL every 4 hours given via syringe as a 10-minute bolus b. 300 mL every 4 hours given via enteral pump as a 45-minute infusion c. 75 mL per hour via enteral pump as a continuous infusion d. 150 mL every 2 hours via gravity infusion

ANS: B Intermittent enteral feedings are an inexpensive and safe method of administering enteral nutrition and may be used when patients are nonambulatory. Three hundred to 400 mL of solution may be given and should infuse over 30 to 60 minutes. While bolus methods may be used for patients receiving 250 to 400 mL of solution, this method is not tolerated well by non-ambulatory patients and may cause nausea, vomiting, aspiration, abdominal cramping, and diarrhea. Continuous feedings are used for critically ill patients. Gravity feedings cannot be well-controlled and may infuse too fast or too slow. REF: Pages 245-246

11. A patient who has been receiving continuous enteral nutrition has had several large, watery stools. The nurse will contact the provider to discuss which intervention? a. Administering antidiarrheal medications b. Slowing the rate of infusion c. Starting total parenteral nutrition d. Thickening the nutrition solution

ANS: B The most common cause of diarrhea during a feeding is dumping syndrome as a result of rapid feed infusion. Slowing the feeding is the appropriate initial action. Antidiarrheal medications are not indicated unless slowing the infusion fails. Total parenteral nutrition is not indicated for patients with a functioning gastrointestinal tract. Thickening the solution will increase the solute load and increase the risk for diarrhea. REF: Page 246

17. The nurse is caring for a patient who is receiving total parenteral nutrition (TPN) and notes that the patient becomes dyspneic when transferring from the bed to a chair. The nurse auscultates rales in both lungs. Which action will the nurse take next? a. Ask the patient to perform the Valsalva maneuver. b. Decrease the TPN rate and request an order for a diuretic medication. c. Obtain an order for a chest radiograph and an antibiotic. d. Stop the TPN and request an order for intravenous isotonic dextrose.

ANS: B The patient who is being treated with TPN and has dyspnea and rales is experiencing fluid overload. The nurse should slow the rate of the TPN and request an order for a diuretic. Patients perform the Valsalva maneuver during bag changes to help prevent pulmonary emboli. Patients receiving TPN are not necessarily at risk for aspiration pneumonia. Intravenous isotonic dextrose is given after sudden interruption of TPN to prevent hypoglycemia. REF: Page 249

16. The nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The patient reports nausea, headache, and thirst. The nurse will contact the provider to discuss a. giving acetaminophen for headache pain. b. obtaining a serum glucose level. c. ordering an antiemetic to prevent vomiting. d. starting intravenous isotonic dextrose.

ANS: B This patient shows signs of hyperglycemia, which is a common adverse effect of TPN. The nurse should request an order for serum glucose. Symptoms should not be treated without first determining the underlying cause. Isotonic dextrose is given to prevent hypoglycemia. REF: Page 249

19. A patient receiving total parenteral nutrition (TPN) begins having cough and dyspnea. The nurse auscultates rales and notes neck vein engorgement and weight gain. The nurse suspects that the patient is experiencing which condition? a. Air embolism b. Fluid overload c. Pneumonia d. Pneumothorax

ANS: B This patient shows signs of overload, characterized by pulmonary edema with cough and dyspnea, neck vein engorgement, and weight gain. REF: Page 249

1. Patients with which conditions would benefit from enteral feedings? (Select all that apply.) a. Burns of face, chest, and neck b. Cerebral palsy with severe dysphagia c. Crohn's disease d. Facial fractures e. Gluten enteropathy f. Stroke

ANS: B, D, F Patients with an intact, functioning gastrointestinal tract will benefit from enteral nutrition. Patients with extensive burns will need total parenteral nutrition (TPN) to prevent negative nitrogen balance. Patients with Crohn's disease and gluten enteropathy have malabsorption problems and will need TPN. REF: Page 244

13. The nurse is preparing to discontinue total parenteral nutrition (TPN) therapy for a patient who has been receiving TPN for several days. The nurse will contact the provider to discuss an order for a. antibiotics. b. intravenous insulin. c. isotonic dextrose. d. nasogastric feedings.

ANS: C Abruptly discontinuing TPN can lead to hypoglycemia. Patients should receive an isotonic dextrose solution for 12 to 24 hours after TPN is discontinued to prevent this reaction. Antibiotics are used when signs of infection are observed. Intravenous insulin would compound hypoglycemia. Nasogastric feedings are indicated if the patient needs continued feeding therapy and has an intact GI tract. REF: Page 248

6. The nurse dilutes an antibiotic before administering it through a patient's nasogastric tube. The patient asks why this is necessary. The nurse explains that diluting the antibiotic helps to a. improve absorption. b. improve hydration. c. prevent diarrhea. d. prevent emboli.

ANS: C Liquid medication must be properly diluted when given through a feeding tube because most liquid medications are hyperosmolar and can cause abdominal distention, cramping, vomiting, and diarrhea. Diluting the liquid medication does not change absorption, improve overall hydration, or prevent embolus formation. REF: Page 246

12. A patient who has been receiving total parenteral nutrition (TPN) for several days accidently removes the intravenous (IV) line. While waiting for the IV therapy nurse, the nurse caring for this patient will monitor for which complication? a. Air embolism b. Dehydration c. Hypoglycemia d. Infection

ANS: C Sudden interruption of TPN therapy can lead to hypoglycemia because of the sudden drop in glucose and the patient's continued increased insulin levels. Air embolism is a complication associated with changing TPN bags. Dehydration is not a complication of a sudden interruption of TPN. Infection is an ongoing concern, but the risk does not increase with a sudden interruption of TPN. REF: Page 248

14. The nurse is caring for a patient with severe burns who will begin receiving total parenteral nutrition (TPN). The patient asks why TPN is necessary. The nurse explains that TPN is used for which reason? a. To minimize pulmonary complications b. To prevent hyperglycemia and fluid overload c. To promote wound healing and maintain cell integrity d. To restore fluid and electrolyte imbalance

ANS: C TPN is indicated for patients with severe burns who are in negative nitrogen balance. TPN enhances wound healing and provides the nutrients necessary to prevent cellular catabolism. While some pulmonary complications, such as aspiration pneumonia, do not occur with TPN, there is a risk of air embolism. Hyperglycemia and fluid overload may occur. REF: Page 248

8. The nurse is preparing to hang a new bag for a patient who is receiving total parenteral nutrition (TPN). During this procedure, the nurse will instruct the patient to take a deep breath and then perform which action? a. Exhale slowly and bear down. b. Exhale slowly to the count of 10. c. Hold the breath and bear down. d. Take several rapid, shallow breaths.

ANS: C Valsalva's maneuver is performed by taking a breath, holding it, and bearing down. Patients are instructed to perform this maneuver in order to prevent the formation of air emboli. REF: Page 250

9. Which patient is most likely to be a candidate for total parenteral nutrition (TPN) rather than enteral nutrition? a. A patient who is comatose after having had a stroke b. A patient who has a fractured mandible following a motor vehicle accident c. A patient who has cerebral palsy and severe dysphagia d. A patient who is pregnant and has intractable hyperemesis gravidarum

ANS: D The patient who is vomiting will be unable to tolerate enteral nutrition. Enteral feedings require a functioning gastrointestinal tract. TPN is more costly and does not carry significant benefits when compared with risks, so it should only be used when enteral nutrition cannot be used. REF: Page 244