Nutrition: Implement and Take Action; Evaluate

What is the maximum amount of time (in minutes) the nurse allows a patient to sit on a bedpan? Record your answer as a whole number. __________minutes

10

Medications administered through a feeding tube should be in liquid form or ground into powder as permitted and dissolved in ______________mL of sterile water before instillation into the tube.

15-30

Which intervention would the nurse implement when caring for a patient who has a nasogastric tube for an intestinal obstruction? Position the air vent above the abdomen. Keep the head of the bed elevated 20 degrees. Allow the unlicensed assistive personnel to insert the tube. Pin tubing to gown to allow for movement.

A

Which parameter would the nurse evaluate to determine the effectiveness of cool packs on a patient's hemorrhoids? Comfort level Fluid intake Fiber intake Mobility level

A

Which potential nutritional deficiencies may occur with a vegetarian diet? Select all that apply. Protein Iron Vitamin B12 Zinc Calcium Vitamin D

A,B,D

Assistance in feeding is appropriate to use for patients with which conditions? Select all that apply. Limited mobility of hands and arms Limited mobility of feet and legs Poor activity tolerance Poor cognitive state Immobile

A,C,D

Which nursing responsibilities are related to percutaneous endoscopic gastrostomy (PEG) tube care? Select all that apply. Flushing the tube regularly Flushing the tube only prior to use Documenting skin assessment Assessing skin around the tube Not changing the dressing until soiled

A,C,D

Which patient scenarios would prompt the nurse to question the prescription of an enema administration? Select all that apply. Patient has glaucoma Patient has a fecal impaction Patient is preoperative for rectal surgery Patient has elevated intracranial pressure Patient is recovering from transurethral resection of the prostate

A,D,E

Foods with a high glycemic index should be avoided in which diet? Cardiac Diabetic Mechanical soft Renal

B

Which action for bowel elimination would the nurse take for a patient who is continent but completely bedbound? Prepare a bedside commode. Offer a bedpan to the patient. Assist the patient to the bathroom. Order adult diapers for the patient.

B

Which action would the nurse take when the patient reports that the enema is causing intermittent pain? Place the patient on a bedpan. Lower the enema bag. Stop the enema immediately. Notify the health care provider.

B

Which evaluation finding would suggest to the nurse that the patient who is taking loperamide is improving? Hard stools are becoming soft. Liquid stools are decreasing. Constipation is resolving. Stools are easy to expel.

B

Which evaluative cue would confirm to the nurse that the patient with a nasogastric tube for a bowel obstruction is progressing as expected? pH of 7 Presence of peristalsis No movement of fluid in the tube Oral temp of 98.6°F (37°C)

B

Which items are included in a clear liquid diet? Milk, juices with pulp, popsicles Gelatin, chicken broth, apple juice Strained soup, milk, cranberry juice Yogurt, gelatin, apple juice

B

Which technique would the nurse use to effectively evaluate proficiency in ostomy care for a patient who is having the spouse perform ostomy care? Have the patient perform a return demonstration. Have the spouse clean and pouch the stoma. Have the patient repeat the steps of the procedure. Have the spouse watch a video with the patient before discharge.

B

Which Healthy People 2030 Core Objective will the nurse consider when planning interventions and establishing patient outcomes specific to nutrition and weight management? Select all that apply. Reduce consumption of polyunsaturated fat in the population aged 2 years and older. Increase consumption of calcium in the population aged 2 years and older. Increase consumption of vitamin D in the population aged 2 years and older. Decrease consumption of potassium in the population aged 2 years and older. Reduce iron deficiency among females aged 12 to 49 years

B,C,E

Which interventions related to mouth care would the nurse take for a patient who is NPO (nothing by mouth)? Select all that apply. Providing small sips of water Brushing teeth Rinsing the mouth with water Providing hard candy Using mouthwash

B,C,E

Which interventions would the nurse take to assist patients in maintaining hygiene needs related to elimination? Select all that apply. Promptly respond to a patient's call for toileting. Perform perineal care after bedpan use. Close the curtains around the patient's bed. Ensure correct placement on the bedpan. Monitor for breaks in the skin.

B,E

Which cue alerts the nurse that the patient with flatus is improving? Passes a soft, formed stool Passes a hard stool with no bradycardia Passes gas with no discomfort Passes a stool with no blood-streaked toilet paper

C

Which description is appropriate for a percutaneous endoscopic gastrostomy (PEG) tube? A feeding tube placed in the stomach through one of the nares A feeding tube placed in the jejunum through one of the nares A feeding tube surgically placed through an incision in the abdomen An intravenous solution placed in a vein

C

Which feeding method would be used for patients who do not have a functioning gastrointestinal (GI) tract or are unable to ingest, digest, or absorb essential nutrients? Nasojejunal (NJ) tube feeds Clear liquid diet Total parenteral nutrition (TPN) Nasogastric (NG) tube feeds

C

Which information regarding the purpose of an ostomy pouch would the wound, ostomy, and continence nurse share with the patient? It reduces fecal drainage. It allows for stoma assessment. It promotes odor control. It enhances self-esteem.

C

Which nursing actions are associated with discharging a patient home with a feeding tube? Select all that apply. Checking the patient's insurance coverage for home tube feedings. Ordering equipment necessary for home tube feedings. Assessing the patient's understanding of this type of nutritional support. Following up with the patient after discharge to ensure the tube feedings are being properly administered. Instructing the patient or caregiver in the proper manner of administering enteral feedings or formula.

C,E

A patient being seen in the outpatient setting 2 weeks after abdominal surgery reports to the nurse that the surgical incision does not seem to be healing well. The patient describes sleeping well, having minimal discomfort, ambulating as directed postoperatively, and tolerating a normal vegan diet. Which foods will the nurse recommend? Leafy green vegetables and oranges Lobster and shrimp Soybeans and flaxseeds Greek yogurt and goat cheese

C. Soybeans and flaxseeds

Which action would the nurse take while administering a noncommercial prepared enema to an adult patient? Angle the tubing straight into the rectum. Squeeze and roll the bottle slowly. Hold the solution bag 8 to 10 inches (20 to 25 cm) above anus. Add the castile soap after the water.

D

Which action would the nurse take while performing ostomy care on a patient with a colostomy? Make the patient clean the stoma. Mix cool water and adhesive remover to gently remove any residue. Clean the area around the stoma with antibacterial soap. Use water to clean the stoma.

D

Which action would the nurse take while providing ostomy care to a patient with a new ileostomy? Allow the unlicensed assistive personnel to clean the stoma. Apply a three-piece ostomy appliance. Collect effluent in the skin barrier. Place the wafer around the stoma.

D