Nutrition & elimination

Factors regarding elimination:

-Doesn't have ability to control urine -urine retention -discomfort -infection & inflammation -neoplasms (abnormal growth of tissue) -organ failure

No control of urine and bowel elimination can lead to?

-skin breakdown -changes in daily activity -changes in social relationships

The nurse is learning about mini nutritional assessmet. What is the highest score in the test?

14 - score of 7 or less indicates malnutrition -score of 8-11 is at risk for malnutrition -score 12-14 indicate normal nutrition

Maximum hang time for enteral feeding system?

8 hr

A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion? a. Cecum, ascending, transverse, descending, sigmoid, and rectum b. Ascending, transverse, descending, sigmoid, rectum, and cecum c. Cecum, sigmoid, ascending, transverse, descending, and rectum d. Ascending, transverse, descending, rectum, sigmoid, and cecum

a

The patient has just started on enteral feedings, and the patient is reporting abdominal cramping. Which action will the nurse take next? a. Slow the rate of tube feeding. b. Instill cold formula to "numb" the stomach. c. Change the tube feeding to a high-fat formula. d. Consult with the health care provider about prokinetic medication

a -One possible cause of abdominal cramping is a rapid increase in rate or volume.

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Limit fluid and caffeine intake before bed. b. Leave the bathroom light on to illuminate a pathway. c. Practice Kegel exercises to strengthen bladder muscles. d. Clear the path to the bathroom of all obstacles before bedtime.

a -Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia

The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address? a. Hyperglycemia b. Hypoglycemia c. Hypercapnia d. Hypocapnia

a -Signs and symptoms of hyperglycemia are thirst, headache, lethargy, and increased urination

When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan? a. Increasing carbohydrates to 55% to 60% of total intake b. Providing vitamin and mineral supplements c. Decreasing protein intake to 0.75 g/kg/day d. Limiting water before and after exercise

a -Sports and regular moderate to intense exercise necessitate dietary modification to meet increased energy needs for adolescents.

A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

a -Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus.

A patient is experiencing oliguria. Which action should the nurse perform first? a. Assess for bladder distention. b. Request an order for diuretics. c. Increase the patient's intravenous fluid rate. d. Encourage the patient to drink caffeinated beverages

a -oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all assessment data to determine the potential cause of oliguria

A nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include? a. Have values for protein, vitamins, and minerals b. Are based on percentages of fat, cholesterol, and fiber c. Have replaced recommended daily allowances (RDAs) d. Are used to develop diets for chronic illnesses requiring 1800 cal/day

a -the RDIs are the first set, comprising protein, vitamins, and minerals based on the RDA.

The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient's skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide? a. Drink more water to prevent further dehydration. b. Drink more calorie-dense fluids to increase caloric intake. c. Drink more milk and dairy products to decrease the risk of osteoporosis. d. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.

a -thirst sensation diminishes, leading to inadequate fluid intake or dehydration; the patient should be encouraged to drink more water/fluids

Which nutrient should be supplied to treat a patient w/ malnutrition effect depressed t- cells distribution? a. folic acid b. copper c. biotin d. vitamin C

a. folic acid

An adult patient has a body mass index of 25kg/m. Which conclusion regarding the patient nutrition status would the nurse formulate? a. overweight b. imbalanced nutrition c. healthy weight d. morbidity obese

a. overweight healthy range for healthy adults= 18.5 - 24.9 kg

Which enteral formula type consists of milk based, blended. foods and by hospital dietary staff or in patients home? a. polymeric b. modular c. elemental d. speciality

a. polymeric appropriate for patients w/ functional gastrointestinal

Which items contain contains gluten and should be avoided in patients w/ celiac disease? select all that apply: a. wheat b. rye c. barley d. oats e. rice

a. wheat b. rye c. barley d. oats

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine? a. Kidney, urethra, bladder, ureters b. Kidney, ureters, bladder, urethra c. Bladder, kidney, ureters, urethra d. Bladder, kidney, urethra, ureters

b

The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria? a. Blood in the urine b. Burning upon urination c. Immediate, strong desire to void d. Awakes from sleep due to urge to void

b -Dysuria is burning or pain with urination

A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? a. Position in semi-Fowler's. b. Flex head with chin tuck. c. Place food on left side. d. Offer fruit juice.

b -Have the patient flex the head slightly to a chin-down position to help prevent aspiration.

Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old female with three final examinations on the same day c. A 40-year-old female with major depressive disorder d. An 80-year-old male in an assisted-living environment

b -Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful.

A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing? a. Resting energy expenditure (REE) b. Basal metabolic rate (BMR) c. Nutrient density d. Nutrients

b -The basal metabolic rate (BMR) is the energy needed at rest to maintain life-sustaining activities for a specific period of time.

In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient? a. Insulin is the only consideration that must be taken into account. b. Saturated fat should be limited to less than 7% of total calories. c. Nonnutritive sweeteners can be used without restriction. d. Cholesterol intake should be greater than 200 mg/day.

b -The diabetic patient should limit saturated fat to less than 7% of total calories and cholesterol intake to less than 200 mg/day.

An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plan of care? a. Functional urinary incontinence b. Urge urinary incontinence c. Impaired skin integrity d. Urinary retention

b -Urge urinary incontinence is the leakage of urine associated with a strong urge to void.

the nurse is conducting 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? a. vitamin A b. vitamin b12 c. vitamin C d. vitamin E

b. vitamin b12

A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1. Elevate head of bed to at least 30 degrees. 2. Check for gastric residual volume. 3. Flush tubing with 30 mL of water. 4. Verify tube placement. 5. Initiate feeding. a. 4, 2, 1, 5, 3 b. 2, 4, 1, 3, 5 c. 1, 4, 2, 3, 5 d. 2, 1, 4, 5, 3

c

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action? a. The patient may void uncontrollably during the procedure. b. Local trauma sometimes promotes excessive urine incontinence. c. Anesthetics can decrease bladder contractility and cause urinary retention. d. The patient will not interrupt the procedure by asking to go to the bathroom.

c -Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness, causing urinary retention.

Which patient will the nurse assess most closely for an ileus? a. A patient with a fecal impaction b. A patient with chronic cathartic abuse c. A patient with surgery for bowel disease and anesthesia d. A patient with suppression of hydrochloric acid from medication

c -Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis

The nurse will anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Endoscopy d. Anorectal manometry

c -Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up? a. Protein level of 2 mg/100 mL b. Urine output of 80 mL/hr c. Specific gravity of 1.036 d. pH of 6.4

c -Dehydration, reduced renal blood flow, and increase in antidiuretic hormone secretion elevate specific gravity

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Broccoli and cheese soup with potato bread b. Turkey and mashed potatoes with brown gravy c. Grape and walnut chicken salad sandwich on whole wheat bread d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing

c -Grapes and whole wheat bread are high fiber and should be chosen.

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea? a. Antibiotic therapy b. Clostridium difficile c. Formula intolerance d. Bacterial contamination

c -Hyperosmolar formulas can cause diarrhea or formula intolerance

A nurse is caring for a male patient with urinary retention. Which action should the nurse take first? a. Limit fluid intake. b. Insert a urinary catheter. c. Assist to a standing position. d. Ask for a diuretic medication.

c -In some patients just helping them to a normal position to void prompts voiding

A nurse is checking orders. Which order should the nurse question? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema for a patient with fluid volume excess c. A Kayexalate enema for a patient with severe hypokalemia d. An oil retention enema for a patient with constipation

c -Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? a. Sigmoid b. Transverse c. Ascending d. Descending

c -The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool (very liquid) would be in the ascending

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most appropriate? a. "Does your urinary problem interfere with any activities?" b. "Do you lose urine when you cough or sneeze?" c. "When was the last time you voided?" d. "Are you experiencing a fever or chills?"

c -To obtain an accurate assessment, the nurse should first determine the source of the discomfort

A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority? a. Reduce dependent nitrogen balance. b. Maintain negative nitrogen balance. c. Promote positive nitrogen balance. d. Facilitate neutral nitrogen balance.

c -When intake of nitrogen is greater than output, the body is in positive nitrogen balance.Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing

In general, when a patient's energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? a. Weight increases. b. Weight decreases. c. Weight does not change. d. Weight fluctuates daily.

c -in general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change.

Which assessment question should the nurse ask if stress incontinence is suspected? a. "Do you think your bladder feels distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"

c -stress incontinence can be related to intraabdominal pressure causing urine leakage, as would happen during coughing or sneezing

A patient has a fecal impaction. Which portion of the colon will the nurse assess? a. Descending b. Transverse c. Ascending d. Rectum

d -A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled.

The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? a. Normal weight b. Underweight c. Overweight d. Obese

d -BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI from 18.5 to 24.9 is normal. BMI under 18.5 is underweight.

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. "This is probably a false negative; we should rerun the test." b. "You should schedule a colonoscopy as soon as possible." c. "Are you under a lot of stress?" d. "Do you take iron supplements?"

d -Certain medications and supplements, such as iron, can alter the color of stool (black or tarry).

The nurse is assessing a patient for nutritional status. Which action will the nurse take? a. Forego the assessment in the presence of chronic disease. b. Use the Mini Nutritional Assessment for pediatric patients. c. Choose a single objective tool that fits the patient's condition. d. Combine multiple objective measures with subjective measures.

d -Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems.

The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." Which information will the nurse include in the teaching session? a. Cholesterol intake needs to be less than 300 mg/day. b. Fats have no significance in health and the incidence of disease. c. All fats come from external sources so this can be easily controlled. d. Deficiencies occur when fat intake falls below 10% of daily nutrition

d -Deficiency occurs when fat intake falls below 10% of daily nutrition.

The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? a. Run lipids for no longer than 24 hours. b. Take down a running bag of TPN after 36 hours. c. Clean injection port with alcohol 5 seconds before and after use. d. Wear a sterile mask when changing the central venous catheter dressing.

d -During central venous catheter dressing changes, always use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection.

A nurse is asked how many kcal per gram fats provided. How should the nurse answer? a.3 b.4 c.6 d.9

d -Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Carbohydrates and protein provide 4 kcal/g.

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? a. Polyunsaturated fats should be less than 7% of the total calories. b. Trans fat should be less than 7% of the total calories. c. Unsaturated fats are found mostly in animal sources. d. Saturated fats are found mostly in animal sources

d -Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids

The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? a. Ileum b. Cecum c. Stomach d. Duodenum

d -The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine.

Which intervention would a nurse perform on a patient who is receiving total parenteral nutrition and is displaying hypoglycemia? a. maintain constant infusion flow rate b. discontinue TPN infusion immediately c. check TPN for supplemental electrolyte levels d. administer an IV bolus of 50% dextrose

d. administer an IV bolus of 50% dextrose - patients w/ hypoglycemia should be assessed for glucose reading then be administer dextrose or glucagon as prescribed

A client is admitted to the long term care facility w/ diagnosis of weight loss secondary to anorexia. The health care provider prescribes an enteral tube feeding standard formula to run 40 ml.hr. A nursing student is assigned to care for the client and the instructor ask the student to describe the nursing considerations in relation for feeding tube. Which indicates an understanding of dietary treatment? a.enteral tube feedings frequently cause sepsis b. enteral feeding should be refrigerated c. caloric value of enteral feeding is b/w 5-10 per milliter d. enteral feedings require the normal digestive capabilities of the GI tract

d. enteral feedings require the normal digestive capabilities of the GI tract

Which factor contributes to peptic ulcer formation? a. spicy foods b. decreased gastrin production c. increased bicarbonate retention d. helicobacter pylori infection

d. helicobacter pylori infection

What is elimination?

excretion of waste from the body - includes urinary & bowel elimination

micturition

urination