Nursing I Test 6

The average daily nutrient intake value estimated to meet the needs of 50% of healthy people in a selected age and gender group is: UL level RDA level AI level EAR level

"Aim to drink approximately 2 L of fluids each day, not including alcohol and caffeine beverages." Explanation: The daily recommended intake of water is approximately 1 ml of water for every kilocalories consumed. There is no evidence to support the recommendation of 8-oz glasses of water, eight times per day. A large glass of water does not need to accompany each and every meal.

Indications for Enteral Nutrition

- cancer - neurological & muscular disorders - GI disorders _ Respiratory failure w/ prolonged intubation - inadequate oral intake

Reasons for NG tube placement?

- enteral feedings - decompression of the stomach - treatment of known or suspected GI obstruction

Cantor tube

- long intestinal tube - weighted by a balled tip filled with 5-8 ml of mercury, water, or saline. - continues into the small intestine either passively or with assistance under fluoroscopy.

What are some possible complications of Enteral Feedings?

-Pulmonary aspiration -Diarrhea -constipation -tube occlusion -abdominal cramping -delayed gastric emptying -electrolyte imbalance -increased respiratory quotient -fluid volume overload or deficit

factors to assess for nutritional status

-Usual dietary intake -Food allergies or intolerances -Food preparation and storage -Dietary practices -Eating disorder patterns

Miller-Abbot intestinal tube

-inflatable latex ballon tip - for aspiration of liquid and air from GI tract - temp. mgmt. of early mechanical obstruction in small and large intestines. - irrigate with saline every 2 hours

BMR for women

0.9 cal/kg of body weight per hours for women.

BMR for men

1 cal/kg of body weight per hour for men.

How to calculate BMI

1. Divide your weight in lbs by your height in inches squared. 2. then multiply the result by a conversion factor of 703. Formula = wt. in lbs. /(ht in inches x ht in inches) x 703

Removing an Enteral Tube

1. remove smoothly & evenly-may get pt to exhale or cough throughout 2. removal of a long intestinal tube is accomplished gradually. 3. 30 cm of tubing is pulled out through the nose once every 1-2 hours and then taped or clamped to prevent slippage. 4. use a towel

Needs Max. comfort w/ min. uncertainty to trust himself/herself, others, and the environment. 1. What Stage (Erikson) is this? 2. What age range?

1. trust vs. mistrust 2. infant

Confirm tube placement

1. use syringe to inject-15 cc of air into stomach while listening with stethoscope at left upper quadrant of abdomen. 2. withdraw air from stomach with syringe & observe for gastric fluid 3. should be able to get back the same amount of air AND some gastric fluid. (check pH, if available) 4. checking with air is NOT considered definitive proof of placement. Must check with more than one method.

Tube Placement Procedure

1. verify order 2. explain procedure 3. wash hands 4. assess patient 5. drape and position pt 6. determine length of tube to be inserted. 7. Lubricate tip of the catheter 8. do not ice plastic tubes 9. do not force-calm patient 10. emphasize need to mouth-breathe during procedure 11. Insert tube through nostril to back of throat (aim down and back) 12. Have pt flex head toward chest 13. encourage pt to swallow as tube passes.

What is a Salem Sump?

A nasogastric tube

The nurse is teaching a community group about reading food labels. When teaching about avoidance of refined sugar, the nurse will teach people to avoid foods containing which ingredients? A. brown sugar B. molasses C. honey D. corn syrup E. corn sweetener

A,B,D,E---MOLASSEES, CORN SYRUP AND CORN SWEETENER, AND BROWN SUGER ARE REFINED SUGARS. HONEY IS NATURALLY OCCURING SUGAR. THEREFORE, CLIENTS DO NOT HAVE TO AVOID HONEY.

enjoys competitive games and sports. The goal of this age group is social contact.

Adolescent 12-19 yrs

Factors that decrease BMR

Aging, prolonged fasting, and sleep

The nurse is assessing adequate nutrition for residents of a long-term care facility. Which strategies are recommended to address age-related changes affecting nutrition? Select all that apply. Eat a high-fiber diet for slowed intestinal peristalsis. Eat more protein for lowered glucose tolerance. Avoid cold liquids with decreased peristalsis in the esophagus. Offer large meals at frequent intervals for reduction in appetite and thirst sensation. Avoid eating right before bedtime for gastroesophageal reflux. Serve one food at a time rather than mixing foods.

Avoid cold liquids with decreased peristalsis in the esophagus. Serve one food at a time rather than mixing foods. Avoid eating right before bedtime for gastroesophageal reflux. Eat a high-fiber diet for slowed intestinal peristalsis. Explanation: To address age-related changes affecting nutrition, the nurse would avoid cold liquids with decreased peristalsis in the esophagus. The nurse would have the client avoid eating right before bedtime for gastroesophageal reflux. The nurse would have the client eat a high-fiber diet for slowed intestinal peristalsis. Small meals, not large meals, should be offered at frequent intervals.

A nursing student is caring for a pt who is receiving enteral feedings though a percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions should the student perform when providing the pts feeds? Select all that apply. A. Calculate the pts intake and output on an hourly basis B. Review the results of the pts lab work whenever it is accessible. C. Keep the height of the pts bed elevated above 30 degrees during feed administration. D. Only mix medications that have an immediate release with the feeds. E. Dilute the formula at a 2:1 ratio with sterile water to promote fluid balance.

B,C,---It is important to review the laboratory results of pts receiving enteral nutrition and to keep the pts head elevated during administration in order to prevent aspiration. Medications cannot be mixed with feeds, and feeds are not normally diluted. The pts intake and output must be monitored, but it is not necessary to do this on an hourly basis.

BMR

Basal Metabolic Rate

A 6-year-old is being cared for on an inpatient unit for treatment of intestinal malabsorption syndrome. What assessment by the nurse would indicate that the child may have calcium deficiency? Select all that apply. Bowed legs Enlarged skull Hypertension Pale mucous membranes Constipation

Bowed legs Enlarged skull Hypertension Explanation: Bowed legs, enlarged, skull, and hypertension are signs that the child may have a calcium deficiency. Constipation may indicate a calcium excess and pale mucous membranes are indicative of iron deficiency.

50-100g of this is needed daily to prevent ketosis.

Carbohydrates

Classified as simple or complex sugars

Carbohydrates

Most abundant and least expensive source of calories in the world

Carbohydrates

Organic compounds composed of Carbon, hydrogen, and oxygen.

Carbohydrates

Serve as the structural framework of plants; lactose is only animal source

Carbohydrates

Sugars & starches are considered?

Carbohydrates

The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? (Select all that apply.) cured ham whole wheat pasta table salt whole milk egg yolks bacon

Check for leaking of gastric contents around the insertion site (e.g., Is the guard too loose or balloon not filled adequately?). Clean around the gastric tube with soap and water, making sure it is adequately rinsed. Keep the head elevated while delivering a gastric feeding and for approximately 1 hour after the feeding. Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall. Explanation: The teaching points that the home health care nurse would include in an education plan would be: checking for leaking of gastric contents around the insertion site; cleaning around the gastric tube site with soap and water; keeping the head elevated while delivering a gastric feeding; and marking the tube with a marker, then checking that the mark is at the level of the abdominal wall.

Risk factors for poor nutritional status

Developmental factors Gender State of health Alcohol abuse Medications Megadoses of nutrient supplements

Which nursing actions follow guidelines for preventing complications with enteral feedings? Select all that apply. Check the residual before intermittent feedings and every 8 hours during continuous feedings. Flush the tube before and after feeding. Give large, infrequent feedings. Clean and moisten the nares every 4 to 8 hours. Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. Change the delivery set every other day according to agency policy.

Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. Flush the tube before and after feeding. Clean and moisten the nares every 4 to 8 hours. Explanation: The head of the bed should be elevated at least 30 degrees during the feeding and for at least 1 hour afterward to prevent the potential of aspiration. The nurse would flush the tube before and after feeding to prevent the tube from potentially clotting. The nurse would clean and moisten the nares every 4 to 8 hours. The nurse would not give large, infrequent feedings, as the body cannot process the feedings with this type of schedule. The delivery set would be changed more often than every other day due to infection control issues. The nurse would check the residual before intermittent feedings, and every 4 to 6 hours during continuous feedings.

Trust vs. Mistrust

Erikson stages of development Infant

Industry vs. Inferiority

Erikson's 4th stage in which a School-aged child tries to develop a sense of self-worth by refining skills.

identity vs. role confusion

Erikson's 5th stage in which adolescents try integrating many roles (child, sibling, student, athlete, worker) into a self-image under role model and peer pressure.

Intimacy vs. Isolation

Erikson's 6th stage in which young adults learn to make personal commitment to another as spouse, parent, or partner.

Generativity vs. Stagnation

Erikson's 7th stage in which MIDDLE AGE ADULTS seek satisfaction through productivity in career, family, and civic interests.

integrity vs despair

Erikson's final stage in which OLDER ADULTS review life accomplishments, deals with loss and preparation for death.

Autonomy vs. Shame and Doubt

Erikson's stage in which a toddler works to master physical environment while maintaining self-esteem.

Initiative vs. Guilt

Erikson's third stage in which a preschooler begins to initiate, not imitate, activities; develops conscience and sexual identity.

An adult patient was admitted to the medical unit with signs and symptoms of dehydration. After the patient's fluid balance was restored, the nurse undertook to teach the patient about adequate fluid intake. The nurse consulted the dietitian's assessment, which noted a healthy body mass index, no obvious nutrient deficiencies, and a 2,000-kcal diet. What should the nurse recommend to this patient? "Aim to drink approximately 2 L of fluids each day, not including alcohol and caffeine beverages." "Try to drink at least 3,000 ml of water each day, and avoid sugary beverages." "Adults should generally drink an 8-oz glass of water, eight times a day." "A good rule of thumb is to start the day with a large glass of water and drink one with each meal."

Establish patterns for meals. Encourage healthy body image. Educate self and family about nutrition. Make time available for food preparation. Explanation: Establishing meal patterns, encouraging healthy body image, educating self and family about nutrition, making time for food preparation, and discouraging food preferences by offering many types of foods in early childhood reflect healthy eating habits. Promoting food preferences in early childhood can inhibit healthy eating behaviors.

The nurse is caring for a client who is vegetarian. Which foods rich in calcium will the nurse recommend? (Select all that apply.) kale bok choy black beans turnip greens fortified soy yogurt flaxseed

FORTIFIED SOY YOGURT BOK CHOY KALE TURNIP GREENS Fortified soy yogurt, bok choy, kale, and turnip greens are rich in calcium. Flaxseed and black beans are rich in omega-3 fatty acids.

Digestion occurs largely in the small intestine

Fats

Insoluble in water and blood.

Fats

A client with anemia has been prescribed injections of B12. Which foods high in this vitamin will the nurse also recommend that the client consume? (Select all that apply.) milk yogurt saltwater fish lean steak peas butter

Grains Vegetables Explanation: Clients should eat 30% grains and 30% vegetables daily. Vegetables and fruits should be consumed as the ratio of 20% for each food group. These food groups are accompanied by low-fat/nonfat milk or other reduced fat dairy products.

Components of Nutritional Assessment

History taking Dietary, medical, socioeconomic data Physical assessments Anthropometric and clinical data Laboratory data Protein status, body vitamin, mineral, and trace element status

When should you immediately withdraw the NG tube during placement?

If pt is coughing or having breathing difficulty

The nurse is teaching a parent of a toddler about healthy eating habits. Which practices will the nurse recommend? (Select all that apply.) Promote food preferences in early childhood. Establish patterns for meals. Encourage healthy body image. Make time available for food preparation. Educate self and family about nutrition.

Increase the number of complex carbohydrates. Decrease the number of calories ingested. Increase physical activity. Explanation: Cutting carbohydrates is not necessary for long-term weight loss. The most beneficial method of long term weight loss is to eat less calories that the client expends. Eating more complex carbohydrates and increasing physical activity will be helpful for creating a healthy weight loss program.

Enjoys playing alone. Physical movements are random and not purposeful.

Infants

Complications of parenteral Nutrition

Insertion problems infection metabolic alterations fluid, electrolyte, and acid-base imbalances phlebitis

Measure what goes in Measure what comes out

Intake&Output

Why do men have higher BMR rates?

Larger muscle mass

These minerals include calcium, phosphorus, and magnesium

Macrominerals

How do you measure a Nasogastric tube for placement?

Measure from the tip of the nose, to the earlobe, and then to the tip of the xyphoid, adding 20-30 cm.

Do men or women have higher BMR rates?

Men

These minerals include iron, zinc, manganese, and iodine.

Microminerals

Inorganic elements found in all body fluids and tissues some function to provide structure in body, others help regulate body processes contained in the ash that remains after digestion

Minerals

What is the preferred method of meeting nutritional needs?

Mouth

Enteral Alternatives

Nasogastric Jejunal Gastric

During an annual physical examination the client reports feeling a lack of muscle energy when walking and doing simple chores around the house. When reviewing the client's diet, deficiencies in which vitamin would be associated with the symptoms reported? Select all that apply. Folic acid Vitamin D Niacin Thiamine Vitamin C

Niacin Thiamine Explanation: Vitamins in the B complex such as niacin and thiamine are associated with confusion and motor weakness.

A client is reporting cracking fissures in the corner of her mouth. Which instruction should the nurse include in the information provided to the client? Increase intake of eggs and milk. Potatoes and other starch containing foods should be restricted. Nuts and legume intake should be increased. Avoid vegetables for the next few weeks.

Occlude both nares until bleeding has subsided. Ensure that client is in upright position. Document epistaxis in client's medical record. Explanation: The nurse would occlude both nares until bleeding subsided. This would help to stop the nosebleed. The nurse would ensure that the client is in the upright position. This will help the client from swallowing blood, which could lead to nausea and emesis. The nurse would document the episode in the client's medical record. The nurse would not contact the primary care provider if the nurse is removing the tube. There would be no need to reinsert the tube if a nosebleed occurred when removing the tube. The nurse would not encourage the client to blow the nose, as this will not help the nosebleed to stop. There would not be blood in the suction container if the nurse is removing the NG tube and the nosebleed occurred.

Enteral nutrtion

Pertaining to the small intestine; also called ENTERIC

At what age do children begin to play WITH other children (cooperative play) rather than "next to" them?

Preschooler

Enjoys watching his/her peers and imitating others, with only some interaction while actually playing. Older children begin to borrow and lend toys. This age group often initiates make-believe play.

Preschooler 4-5 yrs

Labeled complete (high quality) or incomplete (low quality), based on amino acid composition.

Protein

RDA for adults is 0.8g/kg of body weight, 10%-20% total calorie intake

Protein

Required for the formation of all body structures

Protein

Enjoys competitive games and sports, formal board games, and still engages in some fantasy play. Rules are important during play with this aged child...

School-aged Child 6-12 yrs

A nurse is working with a client who is interested in losing weight. What suggestions can the nurse offer to this client in order to promote a heallthy weight loss? Select all that apply. Cut carbohydrates to 45% of intake. Decrease the number of calories ingested. Do not eat anything that is white, such as flour or sugar. Increase the number of complex carbohydrates. Increase physical activity.

The client has malnutrition Explanation: Serum albumin values reflect protein intake or absorption. Values of less than 3.5 g/dL (5 mmol/L) may indicate nutritional deficits and malnutrition or malabsorption.

What age group do you normally find parallel play?

Toddler

Enjoys playing independently with toys. He/she particularly enjoys playing with toys that include body movement.

Toddler 1-3 yrs

Mobiles music boxes stuffed animals mirrors that will not break bells and rattles swings.

Toys for infants 0-6mo.

Blocks balls rattles brightly colored toys cup and spoon teething toys books jack-in-the-box toys that can be pushed and pulled.

Toys for infants 6-12 mo

Slides riding toys wagons, wheelbarrows dolls trucks, cars, airplanes doctor and nurse equip books music toys dress up clothes seesaws small pool skates playhouses nails, hammer, saw play makeup puzzles art supples

Toys for preschooler 4-5 yrs

Puzzles riding toys playground equip. music housework toys toys that can be pushed and pulled rocking horse balls shovel and bucket dolls

Toys for toddlers 1-3 yrs

Affects visual acuity, skin and mucous membranes, and immune function

Vitamin A

Provides calcium and phosphorous metabolism and stimulates calcium absorption.

Vitamin D

An antioxidant that protects Vitamin A

Vitamin E

helps the synthesis of certain proteins necessary for blood clotting

Vitamin K

The nurse is providing an education program to teens. When discussing the role of fat in our bodies, which function can be attributed to fat? Select all that apply. Vitamin absorption Energy Cellular transport Protection from injury Absorption of water-soluble vitamins

Vitamin absorption Protection from injury Energy Cellular transport Explanation: Fat is a component of all body cells and ideally makes up approximately 20% of the body weight of healthy, nonobese people. Fat performs many important functions, including cellular transport, insulation, protection of vital organs in the form of padding, provision of energy, energy storage of adipose tissue, vitamin absorption, and transport of fat-soluble vitamins (vitamins A, D, E, and K).

Accounts for between 50% and 60% of adult's total weight • Two-thirds of body water is contained within the cells (ICF) • Remainder of body water is ECF, body fluids (plasma, intersititial fluid) • Provides fluid medium necessary for all chemical reactions in body • Acts as a solvent and aids digestion, absorption, circulation, and excretion

Water

What is the most accurate means of verifying tube placement?

X-ray

If the fluid you aspirate from an NG tube is acidic, is it from the stomach?

Yes, <7.35 is acidic the pH of gastric acid is 2-3 in the stomach lumen.

Parallel Play

activity in which children play side by side without interacting

Which measures are used by the nurse to confirm the correct placement of a nasogastric feeding tube? Select all that apply. instilling fluid into the tube obtain a chest x-ray after placement as ordered measuring the pH level of aspirated contents measuring tube length monitoring carbon dioxide levels

bacon cured ham table salt Explanation: Sodium is found in higher concentrations in table salt and bacon, and processed meats. The other choices do not have a high concentration of sodium.

Nutrients that supply energy

carbohydrates, protein, lipids

Most concentrated source of energy in the diet

fats

RDA not established, should be less than 30% daily caloric intake

fats

The nurse is teaching a client about the use of MyPlate. Which teaching will the nurse include regarding the food group that should constitute 30% of the client's daily meals? (Select all that apply.) dairy products fruits grains proteins vegetables

grains vegetables Explanation: Clients should eat 30% grains and 30% vegetables daily. Vegetables and fruits should be consumed as the ratio of 20% for each food group. These food groups are accompanied by low-fat/nonfat milk or other reduced fat dairy products.

Factors that increase BMR

growth, infections, fever, emotional tension, extreme environmental temps, elevated levels of certain hormones

A. A home health care nurse is educating a client and caregivers on how to administer an enteral feeding. Which teaching points are appropriate? Select all that apply. B. When checking residuals, routinely discard residuals to prevent an acid-base imbalance. C. Clean around the gastric tube with soap and water, making sure it is adequately rinsed. D. Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall. E. Keep the head elevated while delivering a gastric feeding and for approximately 1 hour after the feeding. F. Check for leaking of gastric contents around the insertion site (e.g., Is the guard too loose or balloon not filled adequately?). G. When cleaning around a gastric tube insertion site, be careful not to rotate the guard after cleaning around it.

lean steak milk yogurt saltwater fish Explanation: Cyanocobalamin, otherwise known as vitamin B12, is found in lean meats, milk and dairy products, and saltwater fish and oysters. It is not found in high concentrations in foods like peas or butter.

Composed of carbon, hydrogen, and oxygen

lipids

The nurse is educating a client with anemia about increasing iron in the diet. Which foods will the nurse teach the client that are high in iron? (Select all that apply.) bananas tofu spinach egg yolks liver processed meat

liver egg yolks tofu spinach Explanation: Liver, egg yolks, tofu, and spinach are high in iron. Processed meats contain excess sodium, and bananas contain high amounts of potassium.

A nurse is removing an NG tube and notes epistaxis. What nursing interventions would the nurse perform in this situation? Select all that apply. Notify primary care provider and anticipate order to reinsert NG tube. Occlude both nares until bleeding has subsided. Ensure that client is in upright position. Record the amount of blood in the suction container. Offer facial tissue to blow nose. Document epistaxis in client's medical record.

measuring the pH level of aspirated contents monitoring carbon dioxide levels obtain a chest x-ray after placement as ordered measuring tube length Explanation: Measuring pH and tube length as well as monitoring carbon dioxide are accurate ways to confirm placement. The gold standard is to obtain a chest x-ray immediately after insertion to determine placement. Fluid would never be instilled and auscultation of air is not considered to be reliable for tube placement.

The nurse is reviewing a client's laboratory report. The report indicates the client's albumin level is 2.89 g/L (4.19 mmol/L). Which inference can the nurse make about the laboratory result? The client has malnutrition The client has been taking steroids. The client has an infection. The client has likely been on a high protein diet.

ncrease intake of eggs and milk. Explanation: The client has presented with symptoms consistent with cheilosis. This may be the result of a Vitamin B2 deficiency. Good sources of this vitamin include milk and eggs.

What is the most accurate nonradiographic method of verifying NG tube placement?

pH measurement of fluid aspirated from tube.

P.E.G. tube

percutaneous endoscopic gastrostomy tube - inserted directly into the stomach through the abdominal wall

animal fats

saturated

vegetable fats

unsaturated

Organic compounds needed in small amounts

vitamins

absorbed through the intestinal wall directly into bloodstream.

vitamins

most are active in the form of coenzymes

vitamins

needed for metabolism of carbs, protein and fat

vitamins

Nutrients that regulate body processes

vitamins, minerals, water