MS 2, Exam 4 (1 of 3): Ch. 38 GI System & 39 Nutritional Problems

FLIP FOR QUESTION

1. Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? a. RUQ b. LUQ c. RLQ d. LLQ ANS: B The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen.

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. 79 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 58-yr-old patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with a wet cloth

a. Offering the patient a pitcher of water Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.

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 is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

a. Place the patient on NPO status. The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.

The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient declined to drink the prescribed laxative solution. b. The patient has had an allergic reaction to shellfish and iodine. c. The patient has a permanent pacemaker to prevent bradycardia. d. The patient is worried about discomfort during the examination.

a. The patient declined to drink the prescribed laxative solution. If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure would be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.

**The nurse is assessing an alert and independent older adult patient for malnutrition risk. Which is the most appropriate initial question? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"

b. "Can you tell me the food that you ate yesterday?" (p. 836, Table 38.7) This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.

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 may have 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.

An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding should the nurse report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/min in each quadrant d. Aortic pulsations visible in the epigastric area

b. Liver edge 3 cm below the costal margin Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. Visible aortic pulsations in the epigastrium, active bowel sounds, and abdominal tympany are within normal findings for an adult of normal weight.

Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical assessment? a. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. c. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt. d. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.

b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.

What action should the nurse take after assisting with a needle biopsy of the liver at a patient's bedside? a. Elevate the head of the bed to facilitate breathing. b. Place the patient on the right side with the bed flat. c. Check the patient's postbiopsy coagulation studies. d. Position a sandbag over the liver to provide pressure.

b. Place the patient on the right side with the bed flat. After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.

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. What should the nurse encourage the patient to increase in the diet? 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.

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds

c. Absent bowel sounds Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.

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/VN)—or registered nurse (RN) —level education and scope of practice.

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's serum potassium level is 2.9 mEq/L. d. The patient has a history of extreme weight fluctuations.

c. 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.

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I take an antacid for indigestion several times a week" d. "I use acetaminophen (Tylenol) every 4 hours for pain."

d. "I use acetaminophen (Tylenol) every 4 hours for pain." Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse but do not indicate a need for patient education.

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. Ask family members to bring favorite foods.

d. Ask family members to 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.

**What condition should the nurse anticipate when caring for a patient with a history of a total gastrectomy? a. Constipation b. Dehydration c. Elevated total serum cholesterol d. Cobalamin (vitamin B12) deficiency

d. Cobalamin (vitamin B12) deficiency The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.

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 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. Difficulty coping b. Disturbed body image c. Impaired nutritional status d. Risk for electrolyte imbalance

d. 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.

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. Stop administering the continuous feeding. d. Measure the gastric residual volume per agency policy.

ANS: C, A, D, B The assessment data indicate that aspiration may have occurred. The nurse's first action should be to turn off the enteral 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 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.

**A patient who has just been started on enteral nutrition of full-strength formula at 100 mL/hr has 6 liquid stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the feeding. b. Check gastric residual volumes more often. 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 feeding. (p. 862, Table 39.12) 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.

**Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment? (Select all that apply.) a. A 35-yr-old patient who reports intermittent nausea for the past 2 days b. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily c. 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 debridement of an infected surgical wound e. A 52-yr-old patient admitted with chest pain and possible myocardial infarction (MI)

b. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily c. 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 debridement 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.

An older patient reports chronic constipation. To promote bowel evacuation, when should the nurse suggest that the patient attempt defecation? a. In the mid-afternoon b. After eating breakfast c. Right after awakening in the morning d. Immediately before the first daily meal

b. After eating breakfast The gastrocolic reflex is most active after the first daily meal. Awakening, the anticipation of eating, and mid-afternoon timing do not stimulate these reflexes.

A severely malnourished patient reports that he is Jewish. What initial action should the nurse take to meet his nutritional needs? a. Have family members bring in food. b. Ask the patient about food preferences. c. Teach the patient about nutritious Kosher foods. d. Order 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.

The nurse is preparing to teach a frail 79-yr-old Hispanic man who lives with an adult daughter about ways to improve nutrition. Which action should the nurse take first? 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 young adult with extensive facial injuries from a motor vehicle crash is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned lying on the left side. b. Flush the tube with 30 mL of water every 4 hours. c. Crush and mix medications in with the feeding formula. d. Obtain a daily abdominal radiograph to verify tube placement.

b. Flush the tube with 30 mL of water every 4 hours. (p. 863) The tube is flushed every 4 hours during continuous feedings to avoid tube obstruction. The patient should be positioned with the head of the bed elevated. Crushed medications mixed in with the formula are likely to clog the tube. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed.

**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 should the nurse 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.

b. Hang a new container of PN and change the IV tubing and filter. (p. 865, Table 39.15) All PN solutions and tubings are changed at 24 hours. Infusion of the additional 50 mL will increase patient risk for infection. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.

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.

What action should the nurse take when caring for a patient with a soft, silicone nasogastric tube in place for enteral nutrition? a. Avoid giving medications through the feeding tube. b. Keep head of bed elevated to 30- to 45-degree angle. c. Replace the tube every 3 days to avoid mucosal damage. d. Administer medications mixed with enteral feeding formula.

b. Keep head of bed elevated to 30- to 45-degree angle. Elevate the head of the bed to decrease the risk of aspiration. 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. Do not mix medications with formula, as the combination can clog the tube.

Which action for a patient receiving enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/VN)? 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 the feedings d. Determining the need for adding water to the feedings

b. Providing skin care to the area around the tube site LPN/VN 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 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. Enteral nutrition 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 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.

The nurse is caring for a patient with an obstructed common bile duct. What condition should the nurse expect? a. Melena b. Steatorrhea c. Decreased serum cholesterol level d. Increased serum indirect bilirubin level

b. Steatorrhea A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.

A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted. Which assessment finding will the nurse expect? 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.

**A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. What is the appropriate action by the nurse? 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. (p. 865, Table 39.15) 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.

While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). What area of patient knowledge should the nurse plan to assess? a. Preventing noninfectious hepatitis b. Treating inflammatory bowel disease c. Risk for developing colorectal cancer d. Using antacids and proton pump inhibitors

c. Risk for developing colorectal cancer FAP is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.

**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 has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.4° F. d. The apical pulse is 100 beats/min.

c. The oral temperature is 101.4° F. A temperature elevation may indicate that an acute perforation has occurred. The other assessment data are normal immediately after the procedure.

Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite b. Occasional indigestion c. Unintended weight loss d. Difficulty chewing food

c. Unintended weight loss Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss.

A patient is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

d. The patient ate a low-fat bagel 4 hours ago for breakfast. Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.