Ch. 39 nutritional problems
Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment (select all that apply)? a. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily b. A 23-yr-old patient who has a history of fluctuating weight gains and losses c. A 35-yr-old patient who complains of intermittent nausea for the past 2 days d. A 64-yr-old patient who is admitted for débridement of an infected surgical wound e. A 52-yr-old patient admitted with chest pain and possible myocardial infarction (MI)
A, B, D a. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily b. A 23-yr-old patient who has a history of fluctuating weight gains and losses d. A 64-yr-old patient who is admitted for débridement of an infected surgical wound Weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest that the patient may be at risk for malnutrition. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.
A healthy adult woman who weighs 145 lb (66 kg) asks the clinic nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend? a. 53 b. 66 c. 75 d. 98
A. 53 The recommended daily protein intake is 0.8 to 1 g/kg of body weight. Therefore, the minimum for this patient is 66 kg ́ 0.8 g = 52.8 or 53 g/day.
A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take? a. Add a new container of PN using the current tubing and filter. b. Hang a new container of PN and change the IV tubing and filter. c. Infuse the remaining 50 mL and then hang a new container of PN. d. Ask the health care provider to clarify the written PN prescription.
A. Add a new container of PN using the current tubing and filter. All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.
Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin supplementation? a. Paresthesias b. Ecchymoses c. Dry, scaly skin d. Gingival swelling
A. Paresthesias Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as paresthesias, peripheral neuropathy, and anemia. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.
A patient who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the tube feeding. b. Check gastric residual volumes more frequently. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.
A. Slow the infusion rate of the tube feeding. Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.
After change-of-shift report, which patient will the nurse assess first? a. A 40-yr-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left b. A 40-yr-old man with continuous enteral feedings who has developed pulmonary crackles c. A 30-yr-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition d. A 30-yr-old woman whose gastrostomy tube is plugged after crushed medications were administered
B. A 40-yr-old man with continuous enteral feedings who has developed pulmonary crackles The patient data suggest aspiration has occurred, and rapid assessment and intervention are needed. The other patients should also be assessed soon, but the data about them do not suggest any immediately life-threatening complications.
A young adult with extensive facial injuries from a motor vehicle crash is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned on the left side. b. Check the gastric residual volume every 4 to 6 hours. c. Avoid giving bolus tube feedings through the PEG tube. d. Obtain a daily abdominal radiographs to verify tube placement.
B. Check the gastric residual volume every 4 to 6 hours. The gastric residual volume is assessed every 4 to 6 hours to decrease the risk for aspiration. The patient does not need to be positioned on the left side. Bolus feedings can be administered through a PEG tube. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily are not needed.
Which action should the nurse take first when preparing to teach a frail 79-yr- old Hispanic man who lives with an adult daughter about ways to improve nutrition? a. Ask the daughter about the patient's food preferences. b. Determine who shops for groceries and prepares the meals. c. Question the patient about how many meals per day are eaten. d. Assure the patient that culturally preferred foods will be included.
B. Determine who shops for groceries and prepares the meals. The family member who shops for groceries and cooks will be in control of the patient's diet, so the nurse will need to ensure that this family member is involved in any teaching or discussion about the patient's nutritional needs. The other information will also be assessed and used but will not be useful in meeting the patient's nutritional needs unless nutritionally appropriate foods are purchased and prepared.
A patient's peripheral parenteral nutrition (PN) bag is nearly empty, and a new PN bag has not arrived yet from the pharmacy. Which intervention by the nurse is appropriate? a. Monitor the patient's capillary blood glucose every 6 hours. b. Infuse 5% dextrose in water until a new PN bag is delivered. c. Decrease the PN infusion rate to 10 mL/hr until a new bag arrives. d. Flush the peripheral line with saline until a new PN bag is available.
B. Infuse 5% dextrose in water until a new PN bag is delivered. To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next peripheral PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurse's scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose every 6 hours would not identify hypoglycemia while awaiting the new PN bag.
Which action for a patient receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient's nutritional status weekly b. Providing skin care to the area around the tube site c. Teaching the patient how to administer tube feedings d. Determining the need for adding water to the feedings
B. Providing skin care to the area around the tube site LPN/LVN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require registered nurse (RN)-level education and scope of practice.
A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest priority? a. Risk for activity intolerance b. Risk for electrolyte imbalance c. Ineffective health maintenance d. Imbalanced nutrition: less than body requirements
B. Risk for electrolyte imbalance The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are also appropriate for this patient but are not associated with immediate risk for fatal complications.
A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports "feeling too tired to eat." Which action should the nurse take first? a. Teach the patient about the importance of good nutrition. b. Serve multiple small feedings of high-calorie, high-protein foods. c. Consult with the health care provider about parenteral nutrition (PN). d. Obtain an order for enteral feedings of liquid nutritional supplements.
B. Serve multiple small feedings of high-calorie, high-protein foods. Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients. Teaching the patient may be appropriate, but will not address the patient's inability to eat more because of fatigue. Tube feedings or PN may be needed if the patient is unable to take in enough nutrients orally, but increasing the oral intake should be attempted first.
A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered? a. Ask the health care provider to reschedule the scan. b. Shut the feeding off 30 to 60 minutes before the scan. c. Connect the feeding tube to continuous suction before and during the scan. d. Send a suction catheter with the patient in case of aspiration during the scan.
B. Shut the feeding off 30 to 60 minutes before the scan. The tube feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.
A severely malnourished patient reports that he is Jewish. The nurse's initial action to meet his nutritional needs will be to a. have family members bring in food. b. ask the patient about food preferences. c. teach the patient about nutritious Kosher foods. d. order nutrition supplements that are manufactured Kosher.
B. ask the patient about food preferences. The nurse's first action should be further assessment whether or not the patient follows any specific religious guidelines that impact nutrition. The other actions may also be appropriate, based on the information obtained during the assessment.
When caring for a patient with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will a. avoid giving medications through the feeding tube. b. flush the tubing after checking for residual volumes. c. replace the tube every 3 days to avoid mucosal damage. d. administer continuous feedings using an infusion pump.
B. flush the tubing after checking for residual volumes. The soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume. Either intermittent or continuous feedings can be given. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes, but flushing after medication administration is important to avoid clogging.
A patient has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in a. iron. b. protein. c. calories. d. carbohydrate.
B. protein The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.
The nurse is planning care for a patient who is chronically malnourished. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Assist the patient to choose high-nutrition items from the menu. b. Monitor the patient for skin breakdown over the bony prominences. c. Offer the patient the prescribed nutritional supplement between meals. d. Assess the patient's strength while ambulating the patient in the room.
C. Offer the patient the prescribed nutritional supplement between meals. Feeding the patient and assisting with oral intake are included in UAP education and scope of practice. Assessing the patient and assisting the patient in choosing high-nutrition foods require licensed practical/vocational nurse (LPN/LVN)-or registered nurse (RN)-level education and scope of practice.
After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL.
C. Surgical incision is healing normally. Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.
A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The appropriate action by the nurse is to a. obtain a venous blood glucose specimen. b. slow the infusion rate of the PN infusion. c. recheck the capillary blood glucose level in 4 to 6 hours. d. contact the health care provider for infusion rate changes.
C. recheck the capillary blood glucose level in 4 to 6 hours. Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, infusion rate changes are not needed. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.
A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find? a. Restlessness b. Hypertension c. Pitting edema d. Food allergies
C.Pitting edema Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take action? (Put a comma and a space between each answer choice [A, B, C, D].) a. Check the patient's oxygen saturation. b. Notify the patient's health care provider. c. Measure the tube feeding residual volume. d. Stop administering the continuous feeding.
D, A, C, B d. Stop administering the continuous feeding. a. Check the patient's oxygen saturation. c. Measure the tube feeding residual volume. b. Notify the patient's health care provider. The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume should be obtained because it provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained.
Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose high-calorie, high-protein foods? a. Baked fish with applesauce b. Beef noodle soup and canned corn c. Fresh fruit salad with yogurt topping d. Fried chicken with potatoes and gravy
D. Fried chicken with potatoes and gravy Foods that are high in calories include fried foods and those covered with sauces. High-protein foods include meat and dairy products. The other choices are lower in calories and protein.
A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake? a. Order six small meals daily. b. Make a referral to the dietitian. c. Teach the patient about high-calorie foods. d. Have family members bring favorite foods.
D. Have family members bring favorite foods. The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked foods might improve intake. The other interventions may also help improve the patient's intake, but the most effective action will be to offer the patient more appealing foods.
A 20-yr-old woman is being admitted with electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? a. The patient uses laxatives daily. b. The patient's knuckles are macerated. c. The patient has a history of extreme fluctuations. d. The patient's serum potassium level is 2.9 mEq/L.
D. The patient's serum potassium level is 2.9 mEq/L. The low serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly. The other information will also be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.
