Chp 24 nutritional care & support
Priority Decision: The nurse is caring for a patient receiving 1000 mL of parenteral nutrition solution over 24 hours. When it is time to change the solution, 150 mL remain in the bottle. What is the most appropriate action by the nurse? a. Hang the new solution and discard the unused solution. b. Open the IV line and rapidly infuse the remaining solution. c. Notify the health care provider for instructions regarding the infusion rate. d. Wait to change the solution until the remaining solution infuses at the proscribed rate.
Correct answer: a Rationale: Bacterial growth occurs at room temperature in nutritional solutions. Therefore solutions must not be infused for longer than 24 hours. Remaining solution should be discard. Speeding up the solution may cause hyperglycemia and should not be done. The health care provider does not need to be notified.
When planning nutritional interventions for a healthy 83-year-old man, the nurse recognizes what factor is most likely to affect his nutritional status? a. Living alone on a fixed income b. Changes in cardiovascular function c. An increase in GI motility and absorption d. Snacking between meal, resulting in obesity
Correct answer: a Rationale: Socioeconomic conditions frequently have the greatest effect on the nutritional status of the healthy older adult. Limited income and social isolation can result in the "tea and toast" meals of the older adult. The other options do not interfere with nutritional status.
When considering tube feedings for a patient with severe protein-calorie malnutrition, what is an advantage of a gastrostomy tube versus a nasogastric (NG) tube? a. There is less irritation to the nasal and esophageal mucosa. b. The patient experiences the sights and smells associated with eating. c. Aspiration resulting from reflux of formulas into the esophagus is less common. d. Routine checking for placement is not required because gastrostomy tubes do not become displaced
Correct answer: a Rationale: Standard nasogastric (NG) tubes are used for tube feedings for short-term feeding problems because prolonged therapy can result in irritation and erosion of the mucosa of the upper GI tract. Gastric reflux and the potential for aspiration can occur with both tubes that deliver fluids into the stomach. Both NG and gastrostomy tubes can become displaced and deprive the patient of the sensations associated with eating.
The percentage of daily calories for a healthy individual consists of a. 50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids. b. 65% carbohydrates, 25% protein, 25% fat, and >10% of fat from saturated fatty acids. c. 50% carbohydrates, 40% protein, 10% fat, and <10% of fat from saturated fatty acids. d. 40% carbohydrates, 30% protein, 30% fat, and >10% of fat from saturated fatty acids.
Correct answer: a Rationale: The 2005 Dietary Guidelines for Americans recommend that 45% to 65% of total calories should come from carbohydrates. Ideally, 10% to 35% of daily caloric needs should come from protein. Individuals should limit their fat intake to 20% to 35% of total calories. Additional recommendations focus on the type of fat consumed because diets high in excess calories, usually in the form of fats, contribute to the development of obesity. Individuals should consume less than 10% of calories from saturated fatty acids, limit intake of fat and oils high in trans fatty acids, and should limit intake of dietary cholesterol to 300 mg/day.
The nurse evaluates that patient teaching about a high-calorie, high-protien diet has been effective when the patient selects which breakfast option from the hospital menu? a. Two poached eggs, hash brown potatoes, and whole milk b. Two slices of toast with butter and jelly, orange juice, and skim milk c. Three pancakes with butter and syrup, two slices of bacon, and apple juice d. Cream of wheat with 2 tbsp of skim milk powder, one half grapefruit, and a high-protein milkshake
Correct answer: a Rationale: The breakfast with the eggs provides 24 g or protein, compared with 14 g for the protein-fortified cream of wheat and milkshake breakfast. Whole milk instead of skim milk helps to meet the calorie requirements. The toast has 10 g of protein and the pancakes have about 6 g. Bacon is considered a fat rather than a meat serving.
The nurse confirms initial placement of a blindly inserted small-bore NG feeding tube by a. x-ray. b. air insufflation. c. observing patient for coughing. d. pH measurement of gastric aspirate.
Correct answer: a Rationale: The nurse should obtain x-ray confirmation to determine whether a blindly placed nasogastric or orogastric tube (small bore or large bore) is properly positioned in the gastrointestinal tract before administering feedings or medications.
What contributes to increased protein-calorie needs? a. Surgery b. Vegan diet c. Lowered temperature d. Cultural or religious beliefs
Correct answer: a Rationale: With surgery a patient will recover more rapidly with a balanced nutritional status before the surgery and increased protein is needed for healing after the surgery. Following a vegan diet does not put the patient at risk of low protein intake. A lowered temperature will not cause increased protein need. Following religious and cultural beliefs would not be expected to affect an increased need for protein.
During assessment of the patient with protein-calorie malnutrition, what should the nurse expect to find (select all that apply)? a. Frequent cold symptoms b. Decreased bowel sounds c. Cool, rough, dry, scaly skin d. A flat or concave abdomen e. Prominent bony structures f. Decreased reflexes and lack of attention
Correct answer: a, b, c, e, f Rationale: In malnutrition, metabolic processes are slowed, leading to increased sensitivity to cold, decreased heart rate (HR) and cardiac output (CO), and decreased neurologic function. Because of slowed GI motility and absorption, the abdomen becomes distended and protruding and bowel sounds are decreased. Skin is rough, dry, and scaly whereas bone structures protrude because of muscle loss. Because the immune system is weakened, susceptibility to respiratory infections is increased.
The stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply)? a. Administer bolus or continuous feedings. b. Evaluate the nutritional status of the patient. c. Administer medications through the gastrostomy tube. d. Monitor for complications related to the tube and enteral feeding. e. Teach the caregiver about feeding via the gastrostomy tube at home.
Correct answer: a, c Rationale: For the stable patient, the LPN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutritional status of the patient, monitor for complications related to the tube and the enteral feeding, and teach the caregiver about feeding via the gastrostomy tube at home.
A 22-year-old female is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient? a. Muscle weakness b. Cardiac dysrhythmias c. Increased urine output d. Anemia and leukopenia
Correct answer: b Rationale: A serum potassium level less than 2.5 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac dysrhythmias (e.g., bradycardia, tachycardia, ventricular dysrhythmias). Other manifestations of potassium deficiency include muscle weakness and renal failure. Patients with anorexia nervosa commonly have iron-deficiency anemia and an elevated blood urea nitrogen level related to intravascular volume depletion and abnormal renal function.
When teaching the older adult about nutritional needs during aging, what does the nurse emphasize? a. Need for all nutrients decreases as one ages. b. Fewer calories, but the same or slightly increased amount of protein, are required as one ages. c. Fats, carbohydrates, and protein should be decreased, but vitamin and mineral intake should be increased. d. High-calorie oral supplements should be taken between meals to ensure that recommended nutrient needs are met.
Correct answer: b Rationale: Although calorie intake should be decreased in the older adult because of decreased activity and basal metabolic rate, the need for specific nutrients, such as proteins and vitamins, does not change.
A patient who has suffered severe burns in a motor vehicle accident will soon be started on parenteral nutrition (PN). Which principle should guide the nurse's administration of the patient's nutrition? a. Administration of PN requires clean technique. b. Central PN requires rapid dilution in a large volume of blood. c. Peripheral PN delivery is preferred over the use of a central line. d. Only water-soluble medications may be added to the PN by the nurse.
Correct answer: b Rationale: Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central line is preferred over the use of peripheral PN, and the nurse may not add any medications to PN.
The nurse is teaching a female patient with type 1 diabetes mellitus about nutrition before discharge. She had surgery to revise a lower leg stump with a skin graft. What food should the nurse teach the patient to eat to best facilitate healing? a. Non-fat milk b. Chicken breast c. Fortified oatmeal d. Olive oil and nuts
Correct answer: b Rationale: High quality protein such as chicken breast is important for tissue repair. Although the non-fat milk, nuts, and fortified oatmeal have some protein, they do not have as much as the chicken breast.
A patient is receiving peripheral parenteral nutrition. The parenteral nutrition solution is completed before the new solution arrives on the unit. The nurse administers a. 20% intralipids. b. 5% dextrose solution. c. 0.45% normal saline solution. d. 5% lactated Ringer's solution
Correct answer: b Rationale: If a peripheral parenteral nutrition (PPN) formula bag empties before the next solution is available, a 5% dextrose solution (based on the amount of dextrose in the peripheral PN solution) may be administered to prevent hypoglycemia.
During starvation, the order in which the body obtains substrate for energy is a. visceral protein, skeletal protein, fat, glycogen b. glycogen, skeletal protein, fat stores, visceral protein c. visceral protein, fat stores, glycogen, skeletal protein d. fat stores, skeletal protein, visceral protein, glycogen
Correct answer: b Rationale: Initially, the body selectively uses carbohydrates (e.g., glycogen) rather than fat and protein to meet metabolic needs. These carbohydrate stores, found in the liver and muscles, are minimal and may be totally depleted within 18 hours. After carbohydrate stores are depleted, skeletal protein begins to be converted to glucose for energy. Within 5 to 9 days, body fat is fully mobilized to supply much of the needed energy. In prolonged starvation, up to 97% of calories are provided by fat, and protein is conserved. Depletion of fat stores depends on the amount available, but fat stores typically are used up in 4 to 6 weeks. After fat stores are used, body or visceral proteins, including those in internal organs and plasma, can no longer be spared and rapidly decrease because they are the only remaining body source of energy available.
A frail 74-year-old man with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. If the man likes all of the items below, which would be the most appropriate for the nurse to suggest? a. Orange juice and dry toast b. Oatmeal, butter, and cream c. Steamed carrots and chicken broth d. Banana and unsweetened applesauce
Correct answer: b Rationale: Oatmeal, butter, and cream are examples of food items that would be appropriate to include for a patient on a high-protein, high-calorie diet.
An older patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse? a. Blood glucose level of 125 mg/dL b. Serum phosphate level of 1.9 mg/dL c. White blood cell count of 10,500/µL d. Serum potassium level of 4.6 mEq/L
Correct answer: b Rationale: Refeeding syndrome can occur if a malnourished patient is started on aggressive nutritional support. Hypophosphatemia (serum phosphate level less than 2.4 mg/dL) is the hallmark of refeeding syndrome and could result in cardiac dysrhythmias, respiratory arrest, and neurologic problems. An increase in the blood glucose level is expected during the first few days after PN is started. The goal is to maintain a glucose range of 110 to 150 mg/dL. An elevated white blood cell count (greater than 11,000/µL) could indicate an infection. Normal serum potassium levels are between 3.5 and 5.0 mEq/L.
A patient who has dysphagia as a consequence of a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into this patient's care? a. Flush the tube with 30 mL of normal saline every 4 hours. b. Flush the tube before and after feedings if the patient's feedings are intermittent. c. Flush the PEG with 100 mL of sterile water before and after medication administration. d. To prevent fluid overload, avoid flushing when the patient is receiving continuous feeding.
Correct answer: b Rationale: The nurse should flush feeding tubes with 30 mL of water (not normal saline) every 4 hours and before and after medication administration during continuous feeding or before and after intermittent feeding. Flushes of 100 mL are excessive and may cause fluid overload in the patient.
Which assessment should the nurse prioritize in the care of a patient who has recently begun receiving parenteral nutrition (PN)? a. Skin integrity and bowel sounds b. Electrolyte levels and daily weights c. Auscultation of the chest and tests of blood coagulability d. Peripheral vascular assessment and level of consciousness (LOC)
Correct answer: b Rationale: The use of PN necessitates frequent and thorough assessments. Key focuses of these assessments include daily weights and close monitoring of electrolyte levels. Assessments of bowel sounds, integument, peripheral vascular system, LOC, chest sounds, and blood coagulation may be variously performed, but close monitoring of fluid and electrolyte balance supersedes these in importance.
The patient cannot afford to buy the food she needs for her family, so she makes sure her children eat first, and then she eats. When she comes to the clinic, she reports bleeding gums, loose teeth, and dry, itchy skin. The nurse should know that this patient is most likely lacking which vitamin? a. Folic acid b. Vitamin C c. Vitamin D d. Vitamin K
Correct answer: b Rationale: This patient is lacking Vitamin C as evidenced by the bleeding gums, loose teeth, and dry, itchy skin. Clinical manifestations of folic acid deficiency include megaloblastic anemia, anorexia, fatigue, sore tongue, diarrhea, or forgetfulness. Clinical manifestations of Vitamin D deficiency include muscular weakness, excess sweating, diarrhea, bone pain, rickets, or osteomalacia. Clinical manifestations of Vitamin K deficiency include defective blood coagulation.
Priority Decision: Before administering a bolus of intermittent tube feeding to a patient with a percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220 mL of gastric contents. How should the nurse respond? a. Return the aspirate to the stomach and recheck the volume of aspirate in an hour. b. Return the aspirate to the stomach and continue with tube feeding as planned. c. Discard the aspirate to prevent over distending the stomach when the new feeding is given. d. Notify the health care provider that the feedings have been scheduled too frequently to allow for stomach emptying.
Correct answer: b Rationale: With intermittent feedings, less than 250 mL residual does not require further action. With continuous feedings and a residual of 250 mL or more after the second residual check, a pro motility agent should be considered.
The patient has parenteral nutrition infusing with amino acids and dextrose. In report, the oncoming nurse is told that the tubing, the bag, and the dressing were changed 22 hours ago. What care should the nurse coming on be prepared to do (select all that apply)? a. Give the patient insulin. b. Check amount of feeding left in the bag. c. Check that the next bag has been ordered. d. Check the insertion site and change the tubing. e. Check the label to ensure ingredients and solution are as ordered.
Correct answer: b,c,e Rationale: The nurse should check the amount of feeding left in the bag, and that the next bag has been ordered to be sure the solution will not run out before the next bag is available. Parenteral nutrition solutions are only good for 24 hours and usually take some time for the pharmacy to mix for each patient. The label on the bag should be checked to ensure that the ingredients and solution are what was ordered. The patient would only receive insulin if the patient is experiencing hyperglycemia and was receiving sliding scale insulin or had diabetes mellitus. The insertion site should be checked, but the tubing is only changed every 72 hours unless lipids are being used.
The nurse recognizes that the majority of patients' caloric needs should come from which source? a. Fats b. Proteins c. Polysaccharides d. Monosaccharides
Correct answer: c Rationale: Carbohydrates should constitute between 45% and 65% of caloric needs, compared with 20% to 35% from fats and 10% to 35% from proteins. Polysaccharides are the complex carbohydrates that are contained in breads and grains. Monosaccharides are simple sugars.
What is an indication for parenteral nutrition that is not an appropriate indication for enteral tube feedings? a. Head and neck cancer b. Hypermetabolic states c. Malabsorption syndrome d. Protein-calorie malnutrition
Correct answer: c Rationale: In malabsorption syndrome, foods that are ingested into the intestinal tract cannot be digested or absorbed and tube feedings infused into the intestinal tract would not be absorbed. All of the other conditions can be treated with enteral or parenteral nutrition, depending on the patient's needs.
The nurse is evaluating the nutritional status of a 55-year-old man who is undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would be the best indicator to determine if the patient has protein-calorie malnutrition? a. Serum transferrin b. C-reactive protein c. Serum prealbumin d. Alanine transaminase (ALT)
Correct answer: c Rationale: In the absence of an inflammatory condition, the best indicator of protein-calorie malnutrition (PCM) is prealbumin; prealbumin is a protein synthesized by the liver and indicates recent or current nutritional status. Decreased albumin and transferrin levels are other indicators that protein is deficient. C-reactive protein (CRP) is elevated during inflammation and is used to determine if prealbumin, albumin, and transferrin are decreased related to protein deficiency or an inflammatory process. Other indicators of protein deficiency include elevated serum potassium levels, low red blood cell counts and hemoglobin levels, decreased total lymphocyte count, elevated liver enzyme levels (ALT), and decreased levels of both fat-soluble and water-soluble vitamins.
Which statement accurately describes vitamin deficiencies? a. The two nutrients most often lacking in the diet of a vegan are vitamin B6 and folic acid. b. Vitamin imbalances occur frequently in the United States because of excessive fat intake. c. Surgery on the GI tract may contribute to vitamin deficiencies because of impaired absorption. d. Vitamin deficiencies in adults most commonly are clinically manifested by disorders of the skin.
Correct answer: c Rationale: Patients who have surgery on the GI tract may be at risk for vitamin deficiencies because of inability to absorb or metabolize them. The strict vegan diet most often lacks cobalamin (vitamin B12) and iron. Although the high intake of fat is a major nutritional problem in the United States, vitamin deficiencies are rare in developed countries except in those with eating disorders or chronic alcohol abusers. Some vitamin deficiencies in adults have neurologic manifestations.
The nurse monitors the laboratory results of the patient with protein-calorie malnutrition during treatment. Which result is an indication of improvement in the patient's condition? a. Decreased lymphocytes b. Increased serum potassium c. Increased serum transferrin d. Decreased serum prealbumin
Correct answer: c Rationale: Serum transferrin is a protein that is synthesized by the liver and used for iron transport and decreases when there is protein deficiency. An increase in the protein would indicate a more positive nitrogen balance with amino acids available for synthesis. Decreased lymphocytes and serum prealbumin are indicators of protein depletion and increased serum potassium shows continuing failure of the sodium-potassium pump.
The nurse is caring for a patient admitted to the hospital for asthma who weighs 186 lb (84.5 kg). During dietary counseling, the patient asks the nurse how much protein he should ingest each day. How many grams of protein does the nurse recommend should be included in the diet based on the patient's current weight? a. 24 b. 41 c. 68 d. 93
Correct answer: c Rationale: The daily intake of protein should be between 0.8 and 1 g/kg of body weight. Thus this patient should take in between 68 and 84 g of protein per day in the diet.
What may occur with failure of the sodium-potassium pump during severe protein depletion? a. Ascites b. Anemia c. Hyperkalemia d. Hypoalbuminemia
Correct answer: c Rationale: The sodium-potassium pump uses 20% to 50% of all calories ingested. When energy sources are decreased, the pump fails to function, sodium and water are left in the cell, and potassium remains in extracellular fluids. Hyperkalemia, as well as hyponatremia, can occur.
The nurse is providing care for a 23-year-old woman who is a strict vegetarian. To prevent the consequences of iron deficiency, what should the nurse recommend? a. Brown rice and kidney beans b. Cauliflower and egg substitutes c. Soybeans and hot breakfast cereal d. Whole-grain bread and citrus fruits
Correct answer: c Rationale: Vegetarians are at a particular risk for iron deficiency, a problem that can be prevented by regularly consuming high-iron foods such as hot cereals and soybeans. The other foods listed are not classified as high sources of iron.
When the nurse identifies an individual at risk for malnutrition with nutritional screening, what is the next step for the nurse to take? a. Supply supplements between meals. b. Encourage eating meals with others. c. Have family bring in food from home. d. Complete a full nutritional assessment.
Correct answer: d Rationale: A full nutritional assessment includes history and physical examination and laboratory data. The nutritional assessment will need to be done to provide the basis for nutrition intervention. The interventions may include supplements if ordered, family bringing food from home, and socializing with meals.
A complete nutritional assessment including anthropometric measurements is important for the patient who a. has a BMI of 25.5 kg/m2. b. complains of frequent nocturia. c. reports a 5-year history of constipation. d. reports an unintentional weight loss of 10 lb in 2 months.
Correct answer: d Rationale: A loss of more than 5% of usual body weight over 6 months, whether intentional or unintentional, is a critical indicator for further assessment.
To evaluate the effect of nutritional interventions for a patient with protein-calorie malnutrition, what is the best indicator for the nurse to use? a. Height and weight b. Body mass index (BMI) c. Weight in relation to ideal body weight d. Mid-upper arm circumference and triceps skinfold
Correct answer: d Rationale: Anthropometric measurements, including mid-upper arm circumference and triceps skinfold measurements, are good indicators of lean body mass and skeletal protein reserves and are valuable in evaluating persons who may have been or are being treated for acute protein malnutrition. The other measurements do not specifically address muscle mass.
What is the most common cause of secondary protein-calorie malnutrition in the United States? a. The unavailability of foods high in protein b. A lack of knowledge about nutritional needs c. A lack of money to purchase high-protien foods d. An alteration in ingestion, digestion, absorption, or metabolism
Correct answer: d Rationale: In the United States, where rote in intake is high and of good quality, protein-calorie malnutrition most commonly results from problems of the GI system. In developing countries, adequate food sources might not exist, the inhabitants may not be well educated about nutritional needs, and economic conditions can prevent purchase of balanced diets.
A patient received a small-bore nasogastric (NG) tube after a laryngectomy. What should be the nurse's priority intervention before starting the enteral feeding? a. Aspiration b. Auscultation of air c. Set head of bed at 40 degrees. d. Verify NG tube placement on x-ray.
Correct answer: d Rationale: It is imperative to ensure that an NG tube is situated in the GI tract rather than the patient's lungs. When an NG tube has been recently inserted, it is important to confirm this placement with an x-ray that will identify the tube's radiopaque tip. Aspiration and air auscultation may not differentiate between gastric and respiratory placement of the tube. The head of bed elevated at least 30 degrees is to prevent aspiration. To determine the maintenance of the feeding tube's proper position, the exit site of the tube is marked at the time of the x-ray and the external portion measured to allow for assessment of a change position with a change in the length of the tube.
Which patient has the highest risk for poor nutritional balance related to decreased ingestion? a. Tuberculosis infection b. Malabsorption syndrome c. Draining decubitus ulcers d. Severe anorexia resulting from radiation therapy
Correct answer: d Rationale: Malnutrition that results form a deceased intake of food is most common in individuals with severe anorexia where there is a decreased desire to eat. Infections created a hypermetabolic state that increases nutritional demand, malabsorption causes loss of nutrients that are ingested, and draining decubitus ulcers are examples of disorders that cause both loss of protein and hypermetabolic states.
The nurse is reviewing the laboratory test results for a 71-year-old patient with metastatic lung cancer. The patient was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. What should this indicate to the nurse? a. The albumin level is normal, and therefore the patient does not have protein malnutrition. b. The albumin level is increased, which is a common finding in patients with cancer who have malnutrition. c. Both the serum albumin and prealbumin levels are reduced, consistent with the admitting diagnosis of malnutrition. d. Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.
Correct answer: d Rationale: Prealbumin has a half-life of 2 days and is a better indicator of recent or current nutritional status. Serum albumin has a half-life of approximately 20 to 22 days. The serum level may lag behind actual protein changes by more than 2 weeks and is therefore not a good indicator of acute changes in nutritional status.
A patient with anorexia nervosa shows signs of malnutrition. During initial referring, the nurse carefully assesses the patient for a. hyperkalemia. b. hypoglycemia. c. hypercalcemia. d. hypophosphatemia.
Correct answer: d Rationale: Refeeding syndrome is characterized by fluid retention, electrolyte imbalances (e.g., hypophosphatemia, hypokalemia, hypomagnesemia), and hyperglycemia. Conditions that predispose patients to refeeding syndrome include long-standing malnutrition states such as those induced by chronic alcoholism, vomiting and diarrhea, chemotherapy, and major surgery. Refeeding syndrome can occur any time a malnourished patient is started on aggressive nutritional support. Hypophosphatemia is the hallmark of refeeding syndrome, and it is associated with serious outcomes, including cardiac dysrhythmias, respiratory arrest, and neurologic disturbances (e.g., paresthesias).
The patient being admitted has been diagnosed with anorexia nervosa. What clinical manifestations should the nurse expect to see on admission assessment? a. Tan skin, blonde hair, and diarrhea b. Sensitivity to heat, fatigue, and polycythemia c. Dysmenorrhea, gastric ulcer pain, and hunger d. Hair loss; dry, yellowish skin; and constipation
Correct answer: d Rationale: The patient with anorexia nervosa, along with abnormal weight loss, is likely to have hair loss; dry, yellow skin; constipation; sensitivity to cold, and absent or irregular menstruation. Other signs of malnutrition are also noted during physical examination.
Priority Decision: An 18-year-old female patient with anorexia nervosa is admitted to the hospital for treatment. On admission she weighs 82 lb (37 kg) and is 5 ft. 3 in (134.6 cm). Her laboratory test results include the following: K+ 2.8 mEq/L (2.8 mmol/L), Hgb 8.9 g/dL (89 g/L), and BUN 64 mg/dL (22.8 mmol/L). In planning care for the patient, the nurse gives the highest priority to which of the following nursing diagnoses? a. Risk for injury related to dizziness and weakness resulting from anemia b. Imbalanced nutrition: less than body requirements related to inadequate food intake c. Risk for impaired urinary elimination related to elevated BUN resulting from renal failure d. Risk for decreased cardiac output (CO) related to dysrhythmias resulting from hypokalemia
Correct answer: d Rationale: The potential life-threatening cardiac complications related to the hypokalemia are the most important immediate considerations in the patient's care. The other nursing diagnoses are important for the patient's care but do not pose immediate risk that the hypokalemia does.
A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Irrigate the tube between feedings. b. Provide wound care at the gastrostomy site. c. Administer prescribed liquid medications through the tube. d.Position the patient with a 45-degree head of bed elevation.
Correct answer: d Rationale: Unlicensed assistive personnel (UAP) may position the patient receiving enteral feedings with the head of bed elevated. A licensed practical nurse/licensed vocational nurse (LPN/LVN) or an RN could perform the other activities.
