nutrition hesi

2Rationale: The client is at risk for hypoglycemia; therefore, the solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of hypoglycemia.

The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit? 1. 5% dextrose in water 2. 10% dextrose in water 3. 5% dextrose in Ringer's lactate 4. 5% dextrose in 0.9% sodium chloride

Liver, egg yolk, whole milk, green or orange vegetables, fruits Fortified milk, fish oils, cereals Vegetable oils; green leafy vegetables; cereals; apricots, apples, and peaches Green leafy vegetables; cauliflower and cabbage

Vitamin A: Vitamin D: Vitamin E: Vitamin K:

hypoglycemia

cold, clammy, dizzy, tachycardia, tingling

air embolism hyperglycemia hypervolemia hypoglycemia infection pneumothorax

complications of PN:

vitamin K

dark green veggies

deep breath and bear down

during a tubing change have the patient

vitamin B

egg yolk, fruit, organ meat, legumes, nuts, veggies, whole grains, milk and dairy, dark green veggies

GI tract IV

enteral = parenteral =

gradually decrease the flow to allow the pancreas to adjust

how to prevent hypoglycemia with TPN

central TPN

in a central large vein (subclavian or jugular) and are placed for longer than 7-10 days

hyperglycemia

increased thirst, increased urine, increased hunger, headache, dehydration, nausea and vomiting, and weakness

BUN electrolytes hematocrit pre albumin glucose

labs to monitor with tube feedings:

vitamin A

liver, milk, egg yolk, dark green veggies, yellow and orange fruit and veggies

megaloblastic anemia

low folic acid causes

calcium

milk, salmon, spinach, kale, wheat, tofu, and OJ

calcium

nerve conduction, muscle contraction, blood vessel dilation, and secretion of hormones

vitamin E

nuts, seeds, oils

vitamin B deficiency

pellagra

B 12 iron

pernicious anemia: sickle cell anemia:

vitamin K

promotes clotting of blood deficiency causes bruising and bleeding

vitamin A

resistance to infection, night vision, helps with growth and development deficiency causes blindness and decreased immunity

air embolism fever infection fluid volume overload blood sugar changes

risks with TPN:

selenium

vegetables, oatmeal, brown rice, chicken, dairy, garlic, onions, seafood, and whole grains

calcium iron vitamin A vitamin C

4 marker nutrients (eat them and you will consume all other nutrients as well)

proteins essential amino acids complete proteins incomplete proteins

1. Amino acids, which make up _____, are critical to all aspects of growth and development of body tissues, and provide 4 cal/g. 2. Build and repair body tissues, regulate fluid balance, maintain acid-base balance, produce antibodies, provide energy, and produce enzymes and hormones. 3. _____ are required in the diet because the body cannot manufacture them. 4. _____ contain all essential amino acids; _____ lack some of the essential fatty acids. 5. Inadequate amounts can cause malnutrition and severe wasting of fat and muscle tissue.

minerals

1. _____ are components of hormones, cells, tissues, and bones. 2. Act as catalysts for chemical reactions and enhancers of cell function. 3. Almost all foods contain some form of them. 4. A deficiency can develop in chronically ill or hospitalized clients. 5. Electrolytes play a major role in osmolality and body water regulation, acid-base balance, enzyme reactions, and neuromuscular activity

carbohydrates

1. _____ are the preferred source of energy. 2. Sugars, starches, and cellulose provide 4 cal/g. 3. Promote normal fat metabolism, spare protein, and enhance lower gastrointestinal function. 4. Major food sources include milk, grains, fruits, and vegetables. 5. Inadequate intake affects metabolism.

dividing the client's weight in kilograms by height in meters squared

Body mass index (BMI) can be calculated by:

High calcium diet

Calcium is needed during bone growth and in adulthood to prevent osteoporosis and to facilitate vascular contraction, vasodilation, muscle contraction, and nerve transmission

Green leafy vegetables; liver, beef, and fish; legumes; grapefruit and oranges Meats, poultry, fish, beans, peanuts, grains Pork and nuts, whole-grain cereals, and legumes Milk, lean meats, fish, grains Yeast, corn, meat, poultry, fish Meat, liver Citrus fruits, tomatoes, broccoli, cabbage

Folic acid: Niacin: Vitamin B1 (thiamine): Vitamin B2 (riboflavin): Vitamin B6 (pyridoxine): Vitamin B12 (cobalamin): Vitamin C (ascorbic acid):

pregnancy, lactation, infancy, childhood, and adolescence

Major stages of the lifespan with specific nutritional needs are _____, _____, _____, _____, and _____. Adults and older adults may experience physiological aging changes, which influence individual nutritional needs.

Full liquid diet

May be used as a transition diet after clear liquids following surgery or for clients who have difficulty chewing, swallowing, or tolerating solid foods

a. Restrict total amounts of fat, including saturated, trans, polyunsaturated, and monounsaturated; cholesterol; and sodium b. Teach the client about the DASH diet or other prescribed diet

Nursing considerations with cardiac/DASH diet:

Mechanical soft

Provides foods that have been mechanically altered in texture to require minimal chewing Used for clients who have difficulty chewing but can tolerate more variety in texture than a liquid diet offers Used for clients who have dental problems, surgery of the head or neck, or dysphagia (requires swallowing evaluation and may require thickened liquids if the client has swallowing difficulties)

Low fiber low residue

Supplies foods that are least likely to form an obstruction when the intestinal tract is narrowed by inflammation or scarring or when gastrointestinal motility is slowed Used for inflammatory bowel disease, partial obstructions of the intestinal tract, gastroenteritis, diarrhea, or other gastrointestinal disorders

4Rationale: The high glucose concentration in PN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul respirations, diuresis, and coma when hyperglycemia is severe. If the client has these symptoms, the blood glucose level should be checked immediately. The remaining options do not identify signs specific to hyperglycemia.

The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia? 1. Fever, weak pulse, and thirst 2. Nausea, vomiting, and oliguria 3. Sweating, chills, and abdominal pain 4. Weakness, thirst, and increased urine output

position on the L side with head lower than feet

what to do if theres a suspected air embolism

Soft diet

Used for clients who have difficulty chewing or swallowing Used for clients who have ulcerations of the mouth or gums, oral surgery, broken jaw, plastic surgery of the head or neck, or dysphagia, or for the client who has had a stroke

High iron diet

Used for clients with anemia

Carbohydrate consistent

Used for clients with diabetes mellitus, hypoglycemia, hyperglycemia, and obesity

High fiber high residue

Used for constipation, irritable bowel syndrome when the primary symptom is alternating constipation and diarrhea, and asymptomatic diverticular disease

vitamin C

antioxidant, collagen synthesis

vitamin E

antioxidant, healthy immune system

B12 pernicious anemia

beefy red tongue is a sign of

vitamin A deficiency

bitot's spots is a sign of

phosphorus

bone development, muscle contraction kidney function, nerve conduction, heart beat regularity

sodium

salt, smoked meat, fish, olives, pickles

assess allergies (eggs) assess cardiac and renal status assess swallow, gag, and bowel sounds patency and intactness of the line check for redness, swelling, erythema, drainage, or broken skin check WBC and RBC counts check vital signs

things to do with TPN:

chloride

tomatoes, celery, seaweed, and olives

beta carotene selenium vitamin E vitamin C

types of antioxidants: (4)

omega 3 & 6

unsaturated essential fatty acids such as fish, nuts, seeds, oil, and flax seed

fluid overload

weak pulse, HTN, tachycardia, concussion, decreased urine OP, pitting edema, JVD, crackles on the lungs

folic acid deficiency fortified grain

what causes neural tube defects: food to increase:

slow the infusion, get vitals, call the doctor, and stay with the patient

what to do with fluid overload

vitamin C

yellow and orange fruits

1. Evaluation of nutritional status by a nutritionist or pharmacist is done before PN is discontinued. 2. If discontinuation is prescribed, gradually decrease the flow rate for 1 to 2 hours while increasing oral intake (this assists in preventing hypoglycemia). 3. After removal of the IV catheter, change the dressing daily until the insertion site heals. Note that central lines should not be left in without a reason due to risk of infection, but in some situations are left in place and used for other necessary reason (venous access, medication administration). 4. Encourage oral nutrition. 5. Record oral intake, body weight, and laboratory results of serum electrolyte and glucose levels. *****Abrupt discontinuation of a PN solution can result in hypoglycemia. The flow rate should be decreased gradually when the PN is discontinued.*****

how to discontinue PN:

egg allergy

determine ___ before giving lipids

vitamin D

development of bone and tissue

vitamin B

every production, makes RBC's and coenzyme

potassium sodium chloride

fluid balance, nerve conduction, and muscle contraction (3)

cereal soy meat

foods to eat to increase B 12

carbs

fruit, sugar, milk, bread, pasta, rice, legumes, starchy veggies

Apples Artichokes Barley Beans Bran Broccoli Brussels sprouts Cabbage Celery Figs Melons Milk Molasses Nuts Onions Radishes Soybeans Wheat Yeast

gas forming foods include:

magnesium

halibut, seeds, nuts, tofu, swiss chard, spinach, wheat, yeast and molasses

saturated fats

hard margarine, shortening, and processed foods (they are hard at room temp)

xray aspirated pH CO2 (would be present if in lungs)

how to check ng tube placement

gluten free

A treatment for celiac disease and gluten sensitivity for clients needing the protein fraction "gluten" eliminated from their diet.

vitamins fat soluble water soluble

1. _____ facilitate metabolism of proteins, fats, and carbohydrates and act as catalysts for metabolic functions. 2. Promote life and growth processes, and maintain and regulate body functions. 3. _____ A, D, E, and K can be stored in the body, so an excess can cause toxicity. 4. The B and C are _____, are not stored in the body, and can be excreted in the urine.

Fat

1. _____ provide a concentrated source and a stored form of energy. 2. Protect internal organs and maintain body temperature. 3. Enhance absorption of the fat-soluble vitamins. 4. Provide 9 cal/g. 5. Inadequate intake of leads to clinical manifestations of sensitivity to cold, skin lesions, increased risk of infection, and amenorrhea in women. 6. Diets high in this can lead to obesity and increase the risk of cardiovascular disease and some cancers.

1, 2, 4, 5Rationale: PN is indicated in clients whose gastrointestinal tracts are not functional or must be rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples of these conditions include those clients with burns, exacerbation of Crohn's disease, and persistent nausea and vomiting due to chemotherapy. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery.

96. The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likelycandidates for parenteral nutrition (PN)? Select all that apply. 1. A client with extensive burns 2. A client with cancer who is septic 3. A client who has had an open cholecystectomy 4. A client with severe exacerbation of Crohn's disease 5. A client with persistent nausea and vomiting from chemotherapy

2Rationale: The client receiving PN at home should have her or his temperature monitored as a means of detecting infection, which is a potential complication of this therapy. An infection also could result in sepsis because the catheter is in a blood vessel. The client's weight is monitored as a measure of the effectiveness of this nutritional therapy and to detect hypervolemia. The pulse and blood pressure are important parameters to assess, but they do not relate specifically to the effects of PN.

A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy? 1. Pulse and weight 2. Temperature and weight 3. Pulse and blood pressure 4. Temperature and blood pressure

4Rationale: Foods that are lower in sodium include fruits and vegetables (summer squash), because they do not contain physiological saline. Highly processed or refined foods (tomato soup, instant oatmeal) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium.

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1. Tomato soup 2. Boiled shrimp 3. Instant oatmeal 4. Summer squash

1Rationale: Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected.

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1. On the left side, with the head lower than the feet 2. On the left side, with the head higher than the feet 3. On the right side, with the head lower than the feet 4. On the right side, with the head higher than the feet

Cheese Collard greens Milk and soy milk Rhubarb Sardines Tofu Yogurt Chloride Salt Breads and cereals Dark green vegetables Dried fruits Egg yolk Legumes Liver Meats Avocado Canned white tuna Cauliflower Cooked rolled oats Green leafy vegetables Milk Peanut butter Peas Pork, beef, chicken Potatoes Raisins Yogurt Fish Nuts Organ meats Pork, beef, chicken Whole-grain breads and cereals Avocado Bananas Cantaloupe Carrots Fish Mushrooms Oranges Pork, beef, veal Potatoes Raisins Spinach Strawberries Tomatoes Bacon Butter Canned food Cheese Cured pork Hot dogs Ketchup Lunch meat Milk Mustard Processed food Snack food Soy sauce Table salt White and whole-wheat bread Eggs Leafy vegetables Meats Protein-rich foods

Calcium: Iron: Magnesium: Phosphorus: Potassium: Sodium: Zinc:

carbohydrates amino acids fat emulsions (lipids) vitamins minerals and trace elements electrolytes water insulin heparin

Components of PN: 1. _____ (60-70%) 2. _____(3.5-20%) 3. _____ (30%) 4. _____ 5. _____ and _____ 6. _____ 7. _____ 8. _____ 9. _____

a. High-fiber diet provides 20 to 35 g of dietary fiber daily b. Volume and weight are added to the stool, speeding the movement of undigested materials through the intestine c. High-fiber foods are fruits and vegetables and whole-grain products d. Increase fiber gradually and provide adequate fluids to reduce possible undesirable side effects such as abdominal cramps, bloating, diarrhea, and dehydration e. Gas-forming foods should be limited

Nursing considerations with a high fiber diet:

a. The high-iron diet replaces iron deficit from inadequate intake or loss. b. The diet includes organ meats, meat, egg yolks, whole-wheat products, dark green leafy vegetables, dried fruit, and legumes. c. Inform the client that concurrent intake of Vitamin C with iron foods enhances absorption of iron.

Nursing considerations with a high iron diet:

a. Purine is a precursor for uric acid, which forms stones and crystals. b. Foods to restrict include anchovies, herring, mackerel, sardines, scallops, organ meats, gravies, meat extracts, wild game, goose, and sweetbreads.

Nursing considerations with a low purine diet:

3, 4, 5Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. 1. Oranges 2. Broccoli 3. Margarine 4. Cream cheese 5. Luncheon meats 6. Broiled haddock

parenteral nutrition (PPN or TPN)

___________ supplies nutrients via the veins. supplies carbohydrates in the form of dextrose, fats in an emulsified form, proteins in the form of amino acids, vitamins, minerals, electrolytes, and water. prevents subcutaneous fat and muscle protein from being catabolized by the body for energy. hypertonic due to the higher concentrations of glucose and addition of amino acids.

Cardiac diet

a. Indicated for atherosclerosis, diabetes mellitus, hyperlipidemia, hypertension, myocardial infarction, nephrotic syndrome, and renal failure b. Reduces the risk of heart disease c. Dietary Approaches to Stop Hypertension (DASH) diet: recommended to prevent and control hypertension, hypercholesterolemia, and obesity d. The DASH diet includes fruits, vegetables, whole grains, and low-fat dairy foods; meat, fish, poultry, nuts, and beans; and is limited in sugar-sweetened foods and beverages, red meat, and added fats.

potassium modified diet

a. Low-potassium diet is indicated for hyperkalemia, which may be caused by impaired renal function, hypoaldosteronism, Addison's disease, angiotensin-converting enzyme inhibitor medications, immunosuppressive medications, potassium-retaining diuretics, and chronic hyperkalemia. b. High-potassium diet is indicated for hypokalemia, which may be caused by renal tubular acidosis, gastrointestinal losses (diarrhea, vomiting), intracellular shifts, potassium-losing diuretics, antibiotics, mineralocorticoid or glucocorticoid excess resulting from primary or secondary aldosteronism, Cushing's syndrome, or exogenous corticosteroid use.

fat restricted diet

a. Used to reduce symptoms of abdominal pain, steatorrhea, flatulence, and diarrhea associated with high intakes of dietary fat, and to decrease nutrient losses caused by ingestion of dietary fat in individuals with malabsorption disorders b. Used for clients with malabsorption disorders, pancreatitis, gallbladder disease, and gastroesophageal reflux

vitamin D

dairy, eggs, liver, fatty fish

1. Clients with severely dysfunctional or nonfunctional gastrointestinal tracts who are unable to process nutrients may benefit from PN. 2. Clients who can take some oral nutrition, but not enough to meet their nutrient requirements, may benefit from PN. 3. Clients with multiple gastrointestinal surgeries, gastrointestinal trauma, severe intolerance to enteral feedings, or intestinal obstructions, or who need to rest the bowel for healing, may benefit from PN. 4. Clients with severe nutritionally deficient conditions such as acquired immunodeficiency syndrome, cancer, burn injuries, or malnutrition, or clients receiving chemotherapy, may benefit from PN.

indications for parenteral nutrition:

phosphorus

milk and meat products

potassium

milk, bananas, legumes, green leafy veggies, OJ, tomatoes, juices, avocado and cantaloupe

polyunsaturated fats (eat less of these)

oils and fish

monounsaturated fats (eat more of these)

oils, almonds, sesame seeds, avocado, cashews

beta carotene

orange, red, yellow, and green veggies

into peripheral vein

peripheral TPN (PPN) only temporarily placed

Foods that are low in potassium include applesauce, green beans, cabbage, lettuce, peppers, grapes, blueberries, cooked summer squash, cooked turnip greens, pineapple, and raspberries

Nursing consideration with a potassium modified diet:

a. Restrict total amount of fat, including saturated, trans, polyunsaturated, and monounsaturated b. Clients with malabsorption may also have difficulty tolerating fiber and lactose c. Vitamin and mineral deficiencies may occur in clients with diarrhea or steatorrhea d. A fecal fat test may be prescribed and indicates fat malabsorption with excretion of more than 6 to 8 g of fat (or more than 10% of fat consumed) per day during the 3 days of specimen collection

Nursing considerations for a fat restricted diet:

a. The Exchange System for Meal Planning, developed by the Academy of Nutrition and Dietetics and the American Diabetes Association, is a food guide that may be recommended. b. The Exchange System groups foods according to the amounts of carbohydrates, fats, and proteins they contain; major food groups include the carbohydrate, meat and meat substitute, and fat groups. c. A carbohydrate consistent diet focuses on maintaining a consistent amount of carbohydrate intake each day and with each meal; also known as "carb counting."

Nursing considerations with a carbohydrate consistent diet:

nutritionally deficient in energy (calories) and many nutrients includes clear and opaque liquid foods, and those that are liquid at body temperature all clear liquids and items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, fruit juices, and strained vegetable juices often necessary to meet nutrient needs for clients on a full liquid diet for more than 3 days

Nursing considerations with a full liquid diet:

a. Primary dietary sources of calcium are dairy products. b. Lactose-intolerant clients should incorporate nondairy sources of calcium into their diet regularly.

Nursing considerations with a high calcium diet:

a. Encourage nutrient-dense, high-calorie, high-protein foods such as whole milk and milk products, peanut butter, nuts and seeds, beef, chicken, fish, pork, and eggs. b. Encourage snacks between meals, such as milkshakes, instant breakfasts, and nutritional supplements.

Nursing considerations with a high calorie high protein diet:

continuous administration intermittent or cyclic administration

________: infused continuously over 24 hours; Most commonly used in a hospital setting ________: commonly administered overnight; Allows clients requiring PN on a long-term basis to participate in activities of daily living during the day without the inconvenience of an IV bag and pump set; Monitor glucose levels closely because of the risk of hypoglycemia due to lack of glucose during non-infusion times.

Clear liquid diet

a. provides fluids and some electrolytes to prevent dehydration. b. is used as an initial feeding after complete bowel rest. c. is used initially to feed a malnourished person or a person who has not had any oral intake for some time. d. is used for bowel preparation for surgery or diagnostic tests, as well as postoperatively and in clients with fever, vomiting, or diarrhea. e. Clear liquid diet is used in gastroenteritis.

calcium iron zinc D

all vegetarians need adequate:

2Rationale: When a client begins eating a regular diet after a period of receiving PN, the PN is decreased gradually. PN that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline does not provide the glucose needed during the transition of discontinuing the PN and could cause the client to experience hypoglycemia.

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? 1. Discontinue the PN. 2. Decrease PN rate to 50 mL/hour. 3. Start 0.9% normal saline at 25 mL/hour. 4. Continue current infusion rate prescriptions for PN.

2Rationale: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk 2. Oranges 3. Bananas 4. Chicken

3Rationale: Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client's signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate sepsis, air embolism, or hyperglycemia.

A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? 1. Sepsis 2. Air embolism 3. Hypervolemia 4. Hyperglycemia

4Rationale: Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, peripheral edema, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume.

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition? 1. Thirst 2. Polyuria 3. Decreased blood pressure 4. Crackles on auscultation of the lungs

4Rationale: When the client who is receiving PN develops a fever, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms per HCP prescription. The other options are incorrect. Because culture for infectious organisms is necessary, the discontinued materials are not discarded or returned to the pharmacy or manufacturer.

A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? 1. Discard them in the unit trash. 2. Return them to the hospital pharmacy. 3. Save them for return to the manufacturer. 4. Prepare to send them to the laboratory for culture.

3Rationale: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in the incorrect options are clear liquids.

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? 1. Tea 2. Gelatin 3. Custard 4. Ice pop

1, 2, 3Rationale: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

intake and output, assessing weight, monitoring for edema, and monitoring for signs of dehydration each kilogram (2.2 lb) of weight gained or lost is equal to 1 liter of fluid retained or lost

Monitor the client's hydration status by assessing (4)

a. Provide enough protein to maintain nutritional status but not an amount that will allow the buildup of waste products from protein metabolism (40 to 60 g of protein daily). b. The less protein allowed, the more important it becomes that all protein in the diet be of high biological value (contain all essential amino acids in recommended proportions). c. An adequate total energy intake from foods is critical for clients on protein-restricted diets (protein will be used for energy, rather than for protein synthesis). d. Special low-protein products, such as pastas, bread, cookies, wafers, and gelatin made with wheat starch, can improve energy intake and add variety to the diet. e. Carbohydrates in powdered or liquid forms can provide additional energy. f. Vegetables and fruits contain some protein and, for very low-protein diets, these foods must be calculated into the diet. g. Foods are limited from the milk, meat, bread, and starch groups.

Nursing considerations with a protein restricted diet:

a. Controlled amounts of protein, sodium, phosphorus, calcium, potassium, and fluids may be prescribed; may also need modification in fiber, cholesterol, and fat based on individual requirements; clients on peritoneal dialysis usually have diets prescribed that are less restrictive with fluid and protein intake than those on hemodialysis b. Most clients receiving dialysis need to restrict fluids c. Monitor weight daily as a priority because weight is an important indicator of fluid status.

Nursing considerations with a renal diet:

a. Individualized; can include 4 g of sodium daily (no-added-salt diet), 2 to 3 g of sodium daily (moderate restriction), 1 g of sodium daily (strict restriction), or 500 mg of sodium daily (severe restriction and seldom prescribed) b. Encourage intake of fresh foods, rather than processed foods, which contain higher amounts of sodium. c. Canned, frozen, instant, smoked, pickled, and boxed foods usually contain higher amounts of sodium. Lunch meats, soy sauce, salad dressings, fast foods, soups, and snacks such as potato chips and pretzels also contain large amounts of sodium; teach patients to read nutritional facts on product packaging regarding sodium content per serving. d. Certain medications contain significant amounts of sodium. e. Salt substitutes may be used to improve palatability; most salt substitutes contain large amounts of potassium and should not be used by clients with renal disease.

Nursing considerations with a sodium restricted diet:

deficient in energy (calories) and many nutrients easily digested and absorbed minimal residue left in GI tract unappetizing and boring intended for short-term use relatively transparent to light and are liquid at body temperature are considered "clear liquids," such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea limit caffeine intake may consume salt and sugar NO dairy or pulp

Nursing considerations with clear liquid diets

a. Foods that are low in fiber include white bread, refined cooked cereals, cooked potatoes without skins, white rice, and refined pasta. b. Foods to limit or avoid are raw fruits (except bananas), vegetables, nuts and seeds, plant fiber, and whole grains. c. Dairy products should be limited to 2 servings a day.

Nursing considerations with low residue diets:

Degree of texture modification depends on individual need, including pureed, mashed, ground, or chopped Foods to be avoided in mechanically altered diets include nuts; dried fruits; raw fruits and vegetables; fried foods; tough, smoked, or salted meats; and foods with coarse textures

Nursing considerations with mechanical soft diets

Clients with mouth sores should be served foods at cooler temperatures Clients who have difficulty chewing and swallowing because of dry mouth can increase salivary flow by sucking on sour candy Encourage the client to eat a variety of foods Provide plenty of fluids with meals to ease chewing and swallowing of foods Drinking fluids through a straw may be easier than drinking from a cup or glass; a straw may not be allowed for clients with dysphagia (because of the risk of aspiration) All foods and seasonings are permitted; however, liquid, chopped, or pureed foods or regular foods with a soft consistency are tolerated best Foods that contain nuts or seeds, which easily can become trapped in the mouth and cause discomfort, should be avoided Raw fruits and vegetables, fried foods, and whole grains should be avoided

Nursing considerations with soft diets:

1. Vegan and vegetarian diets are not usually prescribed but are a diet choice made by a client. 2. Ensure that the client eats a sufficient amount of varied foods to meet nutrient and energy needs. 3. Clients should be educated about consuming complementary proteins over the course of each day to ensure that all essential amino acids are provided. 4. Potential deficiencies in vegetarian diets include energy, protein, vitamin B12, zinc, iron, calcium, omega-3 fatty acids, and vitamin D (if limited exposure to sunlight). 5. To enhance absorption of iron, vegetarians should consume a good source of iron and vitamin C with each meal. 6. Foods eaten may include tofu, tempeh, soy milk and soy products, meat analogs, legumes, nuts and seeds, sprouts, and a variety of fruits and vegetables. 7. Soy protein is considered equivalent in quality to animal protein.

Nursing considerations with vegan and vegetarian diets:

sclerosis, phlebitis, or swelling

The delivery of hypertonic solutions into peripheral veins can cause ... (3)

1Rationale: The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which is indicated in the correct option. The food items in the remaining options are high in sodium, phosphorus, or potassium.

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? 1. Cream of wheat, blueberries, coffee 2. Sausage and eggs, banana, orange juice 3. Bacon, cantaloupe melon, tomato juice 4. Cured pork, grits, strawberries, orange juice

4Rationale: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Legumes are especially rich in this vitamin. Other good food sources include nuts, whole-grain cereals, and pork. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? 1. Milk 2. Chicken 3. Broccoli 4. Legumes

3Rationale: The nurse should plan to secure all connections in the tubing (connections are used per agency protocol). This helps to prevent the restless client from pulling the connections apart accidentally. The nurse should also monitor intake and output, but this does not relate specifically to a risk for injury as presented in the question. Also, monitoring the temperature and blood glucose levels does not relate to a risk for injury as presented in the question. In addition, the client's temperature and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia, respectively.

The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? 1. Calculate daily intake and output. 2. Monitor the temperature once daily. 3. Secure all connections in the PN system. 4. Monitor blood glucose levels every 12 hours.

1Rationale: Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1. Client's temperature 2. Expiration date on the bag 3. Time of last dressing change 4. Tightness of tubing connections

2Rationale: Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

3Rationale: Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and vegetables, which are low in sodium.

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? 1. Apples 2. Bananas 3. Smoked sausage 4. Steamed vegetables

3Rationale: The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate suddenly can cause fluid overload. The same principle (not increasing the rate) applies to parenteral nutrition or any intravenous infusion. Therefore, the remaining options are incorrect.

The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? 1. Adjust the infusion rate to catch up over the next hour. 2. Increase the infusion rate to catch up over the next 2 hours. 3. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate. 4. Adjust the infusion rate to run wide open until the solution is back on time.

4Rationale: The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the intravenous line is on the right, the client turns his or her head to the left. This position increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate and could enhance the potential for an air embolism during the tubing change.

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1. Breathe normally. 2. Turn the head to the right. 3. Exhale slowly and evenly. 4. Take a deep breath, hold it, and bear down.

2Rationale: Fat emulsion (lipids) is a white, opaque solution administered intravenously during parenteral nutrition therapy to prevent fatty acid deficiency. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers of fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Therefore, the remaining options are inappropriate actions.

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? 1. Roll the bottle of solution gently. 2. Obtain a different bottle of solution. 3. Shake the bottle of solution vigorously. 4. Run the bottle of solution under warm water.

3Rationale: The nurse obtains an electronic infusion pump before hanging a PN solution. Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client's blood glucose level is monitored every 4 to 6 hours during administration of PN, a blood glucose meter also will be needed, but this is not the most essential item needed before hanging the solution because it is not directly related to administering the PN. Urine test strips (to measure glucose) rarely are used because of the advent of blood glucose monitoring. Although the blood pressure will be monitored, a noninvasive blood pressure monitor is not the most essential piece of equipment needed for this procedure.

The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution? 1. Urine test strips 2. Blood glucose meter 3. Electronic infusion pump 4. Noninvasive blood pressure monitor

4Rationale: Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? 1. Nuts and milk 2. Coffee and tea 3. Cooked rolled oats and fish 4. Oranges and dark green leafy vegetables

Low purine diet

Used for gout, kidney stones, and elevated uric acid levels

Sodium restricted diet

Used for hypertension, heart failure, renal disease, cardiac disease, and liver disease

Protein restricted

Used for renal disease and end-stage liver disease The nutritional status of critically ill clients with protein-losing renal diseases, malabsorption syndromes, and continuous renal replacement therapy or dialysis should have their protein needs assessed by estimating the protein equivalent of nitrogen appearance (PNA); a nutritionist should be consulted.

High calorie- high protein

Used for severe stress, burns, wound healing, cancer, human immunodeficiency virus, acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, respiratory failure, or any other type of debilitating disease

Renal diet

Used for the client with acute kidney injury or chronic kidney disease and those requiring hemodialysis or peritoneal dialysis

2Rationale: The client beginning infusions of fat emulsions must be first assessed for known allergies to eggs to prevent anaphylaxis. Egg yolk is a component of the solution and provides emulsification. The remaining options are unnecessary and are not related specifically to the administration of fat emulsion.

Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? 1. Ensure that the client does not have diabetes. 2. Determine whether the client has an allergy to eggs. 3. Add regular insulin to the fat emulsion, using aseptic technique. 4. Contact the health care provider (HCP) to have a central line inserted for fat emulsion infusion.

Vegan Lacto-vegetarian Lacto-ovo-vegetarain Ovo-vegetarian

_____ follow a strict vegetarian diet and consume no animal foods; Eat only foods of plant origin (e.g., whole or enriched grains, legumes, nuts, seeds, fruits, vegetables); The use of soybeans, soy milk, soybean curd (tofu), and processed soy protein products enhance the nutritional value of the diet. _____ eat milk, cheese, and dairy foods but avoid meat, fish, poultry, and eggs; A diet of whole or enriched grains, legumes, nuts, seeds, fruits, and vegetables in sufficient quantities to meet energy needs provides a balanced diet. _____ follow a food pattern that allows for the consumption of dairy products and eggs; Consumption of adequate plant and animal food sources that excludes meat, poultry, pork, and fish poses no nutritional risks. _____ only consume eggs, which are an excellent source of complete proteins.

partial parenteral nutrition total parenteral nutrition 10% dextrose in water

_____ is sually administered through a large distal vein in the arm with a standard peripheral intravenous (IV) catheter or midline or through a peripherally inserted central catheter (PICC). A midline is placed in an upper arm vein such as the brachial or cephalic vein with the tip ending below the level of the axillary line; If a PICC cannot be established, the subclavian vein or internal or external jugular veins can be used for PPN. _____ is administered through a central vein; the use of a PICC is acceptable. Other sites that can be used include the subclavian vein and the internal or external jugular veins. If the bag of intravenous solution is empty and the nurse is waiting for the delivery of a new bag of solution from the pharmacy, a ______ in _____ solution should be infused at prescribed rate to prevent hypoglycemia; the prescribed solution should be obtained as soon as possible.

3. Lipid solutions are isotonic and therefore can be administered through a peripheral or central vein; the solution may be administered through a separate IV line below the filter of the main IV administration set by a Y-connector or as an admixture to the PN solution (3-in-1 admixture consisting of dextrose, amino acids, and lipids). 4. Most fat emulsions are prepared from soybean or safflower oil, with egg yolk to provide emulsification; the primary components are linoleic, oleic, palmitic, linolenic, and stearic acids (assess the client for allergies). 5. Glucose-intolerant clients or clients with diabetes mellitus may benefit from receiving a larger percentage of their PN from lipids, which helps to control blood glucose levels and lower insulin requirements caused by infused dextrose. 6. Examine the bottle for separation of emulsion into layers or fat globules or for the accumulation of froth; if observed, do not use and return the solution to the pharmacy. 7. Additives should not be put into the fat emulsion solution. 8. Follow agency policy regarding the filter size that should be used; usually a 1.2-μm filter or larger should be used because the lipid particles are too large to pass through a 0.22-μm filter. 9. Infuse solution at the flow rate prescribed—usually slowly at 1 mL/minute initially—monitor vital signs every 10 minutes, and observe for adverse reactions for the first 30 minutes of the infusion. If signs of an adverse reaction occur, stop the infusion and notify the health care provider (HCP) 10. If no adverse reaction occurs, adjust the flow rate to the prescribed rate. 11. Monitor serum lipids 4 hours after discontinuing the infusion.

how to administer lipids:

A. Check the PN solution with the HCP's prescription to ensure that the prescribed components are contained in the solution; some health care agencies require validation of the prescription by 2 registered nurses. B. To prevent infection and solution incompatibility, IV medications and blood are not given through the PN line. C. Blood for testing may be drawn from the central venous access site; a port other than the port used to infuse the PN is used for blood draws after the PN has been stopped for several minutes (per agency procedure) because the PN solution can alter the results of the sample. The client with a central venous access site receiving PN should still have a venipuncture site. D. Monitor partial thromboplastin time and prothrombin time for clients receiving anticoagulants. E. Monitor electrolyte and albumin levels and liver and renal function studies, as well as any other prescribed laboratory studies. Blood studies for blood chemistries are normally done every other day or 3 times per week (per agency procedures) when the client is receiving PN; the results are the basis for the HCP continuing or changing the PN solution or rate. F. Monitor blood glucose levels as prescribed (usually every 4 hours) because of the risk for hyperglycemia from the PN solution components. G. In severely dehydrated clients, the albumin level may drop initially after initiating PN, because the treatment restores hydration. H. With severely malnourished clients, monitor for "refeeding syndrome" (a rapid drop in potassium, magnesium, and phosphate serum levels). I. The electrolyte shift that occurs in "refeeding syndrome" can cause cardiovascular, respiratory, and neurological problems; monitor for shallow respirations, confusion, weakness, bleeding tendencies, and seizures. If noted, the HCP is notified immediately. J. Abnormal liver function values may indicate intolerance to or an excess of fat emulsion or problems with metabolism with glucose and protein. K. Abnormal renal function tests may indicate an excess of amino acids. L. PN solutions should be stored under refrigeration and administered within 24 hours from the time they are prepared (remove from refrigerator 0.5 to 1 hour before use). M. PN solutions that are cloudy or darkened should not be used and should be returned to the pharmacy. N. Additions of substances such as nutrients to PN solutions should be made in the pharmacy and not on the nursing unit. O. Consultation with the nutritionist should be done on a regular basis (as prescribed or per agency protocol).

nursing considerations with PN:

▪ Chest and back pain ▪ Chills ▪ Cyanosis ▪ Diaphoresis ▪ Dyspnea ▪ Fever ▪ Flushing ▪ Headache ▪ Nausea and vomiting ▪ Pressure over the eyes ▪ Thrombophlebitis ▪ Vertigo

signs and symptoms of an adverse reaction to lipids:

fiber

whole grain, wheat bran, cereals, fruits, veggies and legumes