nutrition and tissue integrity NCLEX questions

When the nurse is evaluating a client who has been taking prednisone 30 mg/day to treat contact dermatitis, which finding is most important to report to the health care provider? 1. The glucose level is 136 mg/dL (7.6 mmol/L). 2. The client states, "I am eating all the time." 3. The client reports frequent epigastric pain. 4. The blood pressure is 148/84 mm Hg.

3. The client reports frequent epigastric pain. Epigastric pain may indicate that the client is developing peptic ulcers, which require collaborative interventions such as the use of antacids, histamine2 receptor blockers, or proton pump inhibitors. The elevation in blood glucose level, increased appetite, and slight elevation in blood pressure may be related to prednisone use but are not clinically significant when steroids are used for limited periods and do not require treatment.

10. Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

10. Answer: 1, 3, 5. A transfer device can pick up a patient and prevent his or her skin from sticking to the bedsheet as he or she is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position causes patient to slide down, causing shear.

9. What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

9. Answer: 1. Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

The nurse is providing care for a patient who is a strict vegetarian. Which would be the best dietary choices the nurse recommends to prevent iron deficiency? a. Brown rice and kidney beans b. Cauliflower and egg substitutes c. Soybeans and hot breakfast cereal d. Whole-grain bread and citrus fruits

Soybeans and hot breakfast cereal 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.

The nurse recognizes that most of a patient's caloric needs should come from which source? a. Fats b. Proteins c. Polysaccharides d. Monosaccharides

Polysaccharides 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.

A patient who has sustained severe burns in a motor vehicle accident is starting parenteral nutrition (PN). Which principle should guide the nurse's administration of PN? 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.

Central PN requires rapid dilution in a large volume of blood. 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 patient with type 1 diabetes who had surgery to revise a lower leg stump with a skin graft about nutrition. What food should the nurse teach the patient to eat to best facilitate healing? a. Nonfat milk b. Chicken breast c. Fortified oatmeal d. Olive oil and nuts

Chicken breast Rationale: High-quality protein such as chicken breast is important for tissue repair. Nonfat milk, nuts, and fortified oatmeal have some protein but not as much as chicken breast.

After identifying that a patient has possible nutritional deficits, which action will the nurse perform next? a. Provide supplements between meals. b. Encourage eating meals with others. c. Have family bring in food from home. d. Complete a full nutritional assessment.

Complete a full nutritional assessment. 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.

Which actions will the nurse use when treating a client with a venous ulcer on the right lower leg? Select all that apply. 1. Position the right leg lower than the heart. 2. Use compression wraps consistently. 3. Administer analgesics before wound care. 4. Maintain a dry wound environment. 5. Encourage right ankle flexion exercises. 6. Clean wound with a nonirritating solution.

Correct Answer: 2,3,5,6 Current guidelines for promotion of venous ulcer healing suggest use of compression, appropriate analgesia, use of exercises to improve venous return, and wound cleansing with a non-irritating solution such as normal saline. The extremity should be elevated to promote venous return and decrease swelling. A moist environment encourages wound healing.

Which priority focused assessments would the nurse perform when caring for a patient recently started on parenteral nutrition (PN)? a. Skin integrity and skin turgor b. Electrolyte levels and daily weights c. Auscultation of lung and bowel sounds d. Peripheral edema and level of consciousness

Electrolyte levels and daily weights Rationale: The use of PN necessitates frequent and thorough assessments. Key assessments include daily weights and close monitoring of electrolyte levels. Assessments of bowel sounds, integument, peripheral edema, level of consciousness, and lung sounds, may be variously performed, but close monitoring of fluid and electrolyte balance supersedes these in importance related to the PN.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? a. A Hispanic female who has a BMI of 24.1 b. An African-American female who is breastfeeding c. An Asian female diagnosed with hypoglycemia d. A Caucasian female who is 39 weeks gestation

b. An African-American female who is breastfeeding Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

A frail older adult with recent severe weight loss is taught to eat a high-protein, high-calorie diet at home. Which foods would the nurse suggest for breakfast? a. Orange juice and dry toast b. Oatmeal with butter and cream c. Banana and unsweetened yogurt d. Waffles with fresh strawberries

Oatmeal with butter and cream Rationale: Oatmeal, butter, and cream are all examples of breakfast items that would be appropriate to include for a patient on a high-protein, high-calorie diet.

5. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When the central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings

5. Answer: 4. When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.

When the nurse must apply containment strategies for a patient with incontinence, what is the major risk? 1. Incontinence-associated dermatitis 2. Skin breakdown 3. Infection 4. Fluid imbalance

2. Skin breakdown A major concern with the use of wearable protective pads is the risk for skin breakdown. Some patients may develop incontinence-associated dermatitis even when the skin is kept free of contact with urine because wearable pads generate heat and sweat in the area and can cause dermatitis. Infection becomes a risk when skin breakdown occurs.

4. A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action? 1. Have the patient turn on the left side and perform a Valsalva maneuver. 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line. 3. Have the patient take a deep breath and hold it. 4. Notify the health care provider immediately

4. Answer: 1. Turn the patient on his or her left side to prevent air from entering the left side of the heart. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down").

4. What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4. Answer: 4, 3, 2, 5, 1. Organized steps ensure a safe, effective irrigation of the wound.

8. When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area

8. Answer: 1, 3. Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

8. Which statement made by the parents of a 2-month-old infant requires further education by the nurse? 1. "I'll continue to use formula for the baby until he is at least a year old." 2. "I'll make sure that I purchase iron-fortified formula." 3. "I'll start feeding the baby cereal at 4 months." 4. "I'm going to alternate formula with whole milk, starting next month."

8. Answer: 4. Infants should not have regular cow's milk during the first year of life. It is too concentrated for the infant's kidneys to manage. There is also an increased risk for developing milk-product allergies.

A patient is being admitted with anorexia nervosa. Which clinical manifestations should the nurse anticipate? a. Sensitivity to heat, fatigue, and polycythemia b. Hair loss; dry, yellowish skin; and constipation c. Tented skin turgor, hyperactive reflexes, and diarrhea d. Dysmenorrhea, hypoactive bowel sounds, and hunger

Hair loss; dry, yellowish skin; and constipation 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 may also be noted during physical examination.

5. Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

5. Answer: 1, 4, 5. Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure injuries.

6. A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees. 3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider.

6. Answer: 3. Delayed gastric emptying is a concern if 250 mL or more remains in a patient's stomach on two consecutive assessments (1 hour apart) or if a single GRV measurement exceeds 500 mL. Therefore the best action is to continue the tube feedings at this time.

6. Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

6. Answer: 4. A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

9. A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? 1. Fastening tube to the gown with new tape 2. Placing client supine while giving a bath 3. Monitoring the client's weight as ordered 4. Ambulating patient with enteral feedings still infusing

9. Answer: 2. A patient receiving continuous enteral feedings should never be placed supine because it increases the risk for pulmonary aspiration. If the nurse needs to lay the patient in the supine position, the feedings should be stopped and restarted when the head of the bed is at 45 degrees.

The nurse in the skilled nursing facility is very busy and unable to answer all the call lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply.) a. Assessing a patient complaining of an itching rash b. Assisting the client with frequent turning to prevent pressure ulcers c. Covering the client who complains of being cold with more blankets d. Placing a sterile gauze pad over broken skin to contain drainage e. Applying over-the-counter lotions to skin that is not broken

B, C, D, E All the above options can be delegated to an unlicensed assistive personnel employee except assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

The stable patient has a gastrostomy tube for enteral nutrition. Which care could the RN delegate to the LPN/VN? (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 receiving enteral nutrition. e. Teach the caregiver about feeding via the gastrostomy tube at home.

Administer bolus or continuous feedings. Administer medications through the gastrostomy tube. 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 enteral nutrition, and teach the caregiver about feeding via the gastrostomy tube at home.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.) a. Waist-to-hip ratio of 1.0 b. Hematocrit level of 50% c. Weight loss of 6% since last month's visit d. Hemoglobin level of 8.2 g/dL e. Body mass index (BMI) of 17 f. Prealbumin level of 16 mg/dL

B, C, D A BMI of 18.5-24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14-18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15-36 mg/dL. A hematocrit level of 50% is within normal limits.

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. Give prescribed liquid medications through the tube. d. Position the patient with a 45-degree head of bed elevation.

Position the patient with a 45-degree head of bed elevation. Rationale: UAP may position the patient receiving enteral feedings with the head of bed elevated. The LPN/VN or an RN could perform the other activities.

Liquid supplemental iron is prescribed for a 10-month-old child with iron deficiency anemia. The parents tell the nurse that their child hates the taste of medicine. Which of the following instructions should the nurse provide to the parents? Select all that apply. 1. Give the iron orally with a syringe. 2. Mix the iron in a little bit of chocolate syrup. 3. Give the iron with food or milk. 4. Let the child drink the iron through a straw. 5. Give the iron with orange juice.

1. Give the iron orally with a syringe. 5. Give the iron with orange juice. Iron supplementation can stain the teeth and has an unpleasant taste. By administering the iron with a syringe to the back of the throat, it will mask the taste and prevent staining of the teeth. The vitamin C in orange juice increases iron absorption and may mask the unpleasant taste. Chocolate contains caffeine, which interferes with the absorption of iron. Milk and food also interfere with the absorption of iron. Although allowing a child to drink the iron through a straw is feasible for an older child, a 10-month-old child cannot developmentally perform this task.

1. The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea

1. Answer: 2, 3, 4. Patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, skin breakdown, sepsis, or hemorrhage during hospitalization.

1. When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

1. Answer: 4. When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

A 2-year-old child arrives at the health center for a routine well-child visit. A complete blood count and lead level are obtained. The lead level is less than 10 mcg/dL (0.483 μmol/L). The hemoglobin is 8 g/dL (80 g/L). The hematocrit is 24% (0.24 volume fraction), and the mean corpuscular volume (MCV) is 65 μm3 (65 fL). What questions should the nurse ask the parent to obtain a more thorough history? Select all that apply. 1. Does your child eat nonfood substances? 2. Is your child more prone to infections? 3. Has your child experienced hair loss? 4. Does your child frequently have nosebleeds? 5. How much milk does your child drink?

1. Does your child eat nonfood substances? 5. How much milk does your child drink? Iron deficiency anemia is a microcytic anemia. Laboratory findings consistent with iron deficiency anemia include low hemoglobin, hematocrit, and MCV. Additionally, the patient may have thrombocytosis, which is an increase in the number of platelets; so the child will not be more likely to have nosebleeds. The white blood cell count (WBC) and WBC differential are not affected by anemia; therefore, the child will not be more prone to infections. Children with iron deficiency anemia experience pica, which is a consumption of nonfood items. Excessive cow's milk intake has been found to cause anemia by irritating the intestine and resulting in microscopic blood loss from the gastrointestinal tract.

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? 1. Encourage the patient to eat foods that are high in calories and protein. 2. Feed the patient as quickly as possible to prevent early satiety. 3.Offer lots of fluids between bites of food. 4. Try to get the patient to eat everything on the tray.

1. Encourage the patient to eat foods that are high in calories and protein. Patients with COPD often have food intolerance, nausea, early satiety (feeling too "full" to eat), poor appetite, and meal-related dyspnea. The increased work of breathing raises calorie and protein needs, which can lead to protein-calorie malnutrition. Urging the patient to eat high-calorie, high-protein foods can be done by the UAP after the nurse has taught the patient about the importance of this strategy to prevent weight loss. Feeding the patient too rapidly will tire him or her. If early satiety is a problem, avoid fluids before or during the meal or provide smaller, more frequent meals.

Clients who are undernourished or starved for prolonged periods are at risk for refeeding syndrome when nourishment is first given. What is the priority nursing assessment to prevent complications associated with this syndrome? 1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. 2. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention. 3. Observe for signs of secret purging and ingestion of water to increase weight. 4. Assess for alternating constipation and diarrhea and pale clay-colored stools.

1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. Refeeding syndrome occurs when aggressive and rapid feeding results in fluid retention and heart failure. Electrolytes, especially phosphorus, should be monitored, and the client should be observed for signs of fluid overload. Changes in bowel sounds, nausea, and distention may occur but are also appropriate for any client with nutritional issues or for clients receiving enteral feedings. Observing for purging and water ingestion would be appropriate for a client with an eating disorder. Changes in stool patterns may occur but are not related to refeeding syndrome.

A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? 1. Position the client sitting up in bed before he or she is fed. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly because there are three more clients to feed. 4. Suction the client's secretions between bites of food.

1. Position the client sitting up in bed before he or she is fed. Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding.

The health care provider (HCP) prescribes permethrin application for all family members of a client who has scabies. Which client information will be most important for the nurse to discuss with the HCP before client teaching about the medication? 1. The client has a newborn infant. 2. Burrows are noted on the wrists. 3. The client and family are homeless. 4. Family members are asymptomatic.

1. The client has a newborn infant. Although all family members (symptomatic or not) should be treated for scabies, permethrin is contraindicated in clients who are younger than 2 months of age because of concerns that the medication may be absorbed systemically. Burrows on the wrist are commonly seen with scabies. The client's homelessness may affect teaching about how to launder clothes and linens but will not impact on use of permethrin for treating the scabies infestation.

10. A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) 1. Change the dressing using sterile technique. 2. Change TPN containers every 48 hours. 3. Change the TPN tubing every 24 hours. 4. Monitor glucose levels to watch and assess for glucose intolerance. 5. Elevate head of the bed 45 degrees to prevent aspiration.

10. Answer: 1, 3. The central line is inserted into a large vein that leads to the superior vena cava. This increases risk for infection. Therefore to prevent infection, change the TPN infusion tubing every 24 hours. Do not hang a single container of PN for more than 24 hours or lipids more than 12 hours. Use sterile technique during central line dressing changes (see Chapter 42). Monitoring glucose levels and elevating the head of bed are not interventions that will prevent central line infections.

2. Match the pressure injury stages with the correct definition. 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4 a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serumfilled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive- related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. c. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/ or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. d. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/ or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

2. Answer: 1b, 2a, 3d, 4c.

Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. The nurse finds that the wound edges are open, and loops of intestine are protruding. Which action should the nurse take first? 1. Notify the surgeon that wound evisceration has occurred. 2. Cover the wound with saline-soaked dressings. 3. Use swabs to obtain aerobic and anaerobic wound cultures. 4. Call for assistance from the Rapid Response Team (RRT).

2. Cover the wound with saline-soaked dressings. The initial action should be to ensure that the abdominal contents remain moist by covering the wound and loops of intestine with dressings soaked with sterile normal saline. Because national guidelines addressing the use of RRTs indicate that the role of the RRT is immediate assessment and stabilization of the client, the nurse's next action should be to activate the RRT. The surgeon should be notified after further assessments of the client (e.g., pulse and blood pressure) are obtained. Wound cultures may be obtained, but protection of the wound, further assessment of the client, and then notification of the surgeon so that other actions can be taken are the priority.

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy

2. Encouraging, monitoring, and recording nutritional intake The UAP's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the UAP can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill and are appropriate to the RN's scope of practice. Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN's scope of practice.

Two unlicensed assistive personnel (UAP) are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs requires the nurse's immediate intervention? 1. Positioning themselves on opposite sides of the patient's bed 2. Grasping under the patient's arms to pull him up in bed 3. Lowering the side rails of the patient's bed before moving him 4. Removing the pillow before moving the patient up in bed

2. Grasping under the patient's arms to pull him up in bed Patients with Cushing disease usually have paper-thin skin that is easily injured. The UAPs should use a lift or a draw sheet to carefully move the patient and prevent injury to the skin. All of the other actions are appropriate to moving this patient up in bed.

A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is transferred to the emergency department. Which prescribed intervention will the nurse implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.

2. Rinse the back and legs with 4 L of sterile normal saline. With chemical injuries, it is important to remove the chemical from contact with the skin to prevent ongoing damage. The other actions also should be accomplished rapidly; however, rinsing the chemical off is the priority for this client.

3. After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder

3. Answer: 1, 4. If a patient has an opening in the surgical incision and a part of the small bowel is noted, this is evisceration. The small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

3. The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her

3. Answer: 4. Stop feeding and then place patient on side. If choking persists, suction airway. Notify health care provider. Keep patient NPO

A pregnant woman at 12 weeks' gestation tells the nurse that she is a vegetarian. What would be the first appropriate nursing action? 1. Recommend vitamin B12 and iron supplementation. 2. Recommend consumption of protein drinks daily. 3. Obtain a 24-hour diet recall history. 4. Determine the reason for her vegetarian diet.

3. Obtain a 24-hour diet recall history. The care of a vegetarian woman who is pregnant should begin with assessment of her diet, because vegetarian practices vary widely. The RN must first assess exactly what the woman's diet consists of and then determine any deficiencies. The reason for the diet is less important than what the diet actually contains. It is probable that the woman will need a vitamin B12 supplement, but the assessment comes first. Vegetarian diets can be completely adequate in protein, and therefore protein supplementation is not routinely recommended.

The nurse is caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. Which indicator is the most reliable for tracking fluid retention? 1. Auscultating the lung fields for crackles every day 2. Measuring the abdominal girth every morning 3. Performing daily weights with the same amount of clothing 4. Checking the extremities for pitting edema and comparing with baseline

3. Performing daily weights with the same amount of clothing All of these measures should be performed for total care of the client; however, weighing the client every day is considered the single best indicator of fluid volume.

The home health nurse is caring for a client with a fungal infection of the toenails who has a new prescription for oral itraconazole. Which client information is most important to discuss with the health care provider (HCP) before administration of the itraconazole? 1. The client's toenails are thick and yellow. 2. The client is embarrassed by the infection. 3. The client is also taking simvastatin daily. 4. The client is allergic to iodine and shellfish.

3. The client is also taking simvastatin daily. The "azole" antifungal medications inhibit drug-metabolizing enzymes (when used orally or intravenously) and can lead to toxic levels of many other medications, including some commonly prescribed statins. Thick and yellow toenails are typical with fungal infections in this area, and clients may be embarrassed by the appearance of the nails, but antifungal treatment will improve the appearance of the nails. The client's iodine allergy will be reported to the HCP but will not impact on use of itraconazole.

An 18-month-old child has oral mucositis secondary to chemotherapy. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Feeding the child a bland, moist, soft diet

4. Feeding the child a bland, moist, soft diet Helping the child to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. An 18-month-old child is not able to swish and spit, which could result in swallowing the mouthwash. Mouthwash is not intended for swallowing because it can contain alcohol and other ingredients not safe for ingestion.

The nurse would be most concerned about a prescription for a total parenteral nutrition (TPN) fat emulsion for a client with which condition? 1. Gastrointestinal (GI) obstruction 2. Severe anorexia nervosa 3. Chronic diarrhea and vomiting 4. Fractured femur

4. Fractured femur A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used in clients with GI obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting.

The nurse provides postoperative care for a client who had total abdominoperineal resection surgery. Which position would the nurse encourage the client to maintain when in bed to promote perineal wound healing? 1. Knee-chest 2. Dorsal recumbent 3. Left or right Sims 4. Left or right side-lying

4. Left or right side-lying The left or right side-lying position puts the least strain or pressure on the perineal suture line. The knee-chest position is difficult to maintain and places stress on the suture line. The dorsal recumbent position places undue stress on the suture line and is the most uncomfortable position. Flexion of one hip and knee will increase tension on the perineal suture line.

An adolescent girl is admitted to the medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium level is 3.5 mEq/L (3.5 mmol/L), and she has experienced weight loss of more than 25% within the past 3 months. What is the primary collaborative goal? 1. Assist her to increase feelings of control. 2. Decrease power struggles over eating. 3. Resolve dysfunctional family roles. 4. Restore normal nutrition and weight.

4. Restore normal nutrition and weight. If the patient meets the criteria for admission to a medical-surgical unit, nutritional restoration is the primary concern. Concurrently, the health care team will assist the patient to achieve success in the other areas.

7. Which action can a nurse delegate to assistive personnel (AP)? 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client's tolerance of the enteral feeding

7. Answer: 1. The skills of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to AP. The nurse needs to administer enteral feeding because of the risk of aspiration. The nurse is responsible for teaching the client and evaluating the tolerance to the enteral feeding.

7. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

7. Answer: 2, 4. A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

Appropriate approaches used by the long-term care nurse to provide education for a 73 year old who has just been diagnosed with diabetes include which of the following? (Select all that apply.) a. Encourage the patient's family to participate in teaching sessions. b. Avoid discussion of the patient's favorite foods. c. Remind the patient that a lot of damage has already occurred. d. Schedule a visit by another resident who is diabetic. e. Demonstrate food choices using food photographs. f. Ask the patient about past experiences with lifestyle changes.

A, D, E, F Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

The nurse is performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps in the order in which each should be accomplished. 1. Cover the wound with a sterile gauze dressing. 2. Débride the wound of eschar using gauze sponges. 3. Obtain specimens for aerobic and anaerobic wound cultures. 4. Apply silver sulfadiazine ointment. 5. Administer morphine sulfate 10 mg IV.

Administer morphine sulfate 10 mg IV. Débride the wound of eschar using gauze sponges. Obtain specimens for aerobic and anaerobic wound cultures. Apply silver sulfadiazine ointment. Cover the wound with a sterile gauze dressing. Pain medication should be administered before changing the dressing because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be débrided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained before the application of antibacterial creams. The antibacterial cream should then be applied to the area after débridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing.

2. The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN

Answer: 1, 5. When a client is malnourished, he or she is in a state of negative nitrogen balance—meaning, the body is experiencing protein loss and requires more protein to maintain healing. Therefore, total protein will indicate the amount of muscle breakdown and protein loss. Albumin is a serum binding protein, and lower levels can be an indicator of malnutrition, but it is really more indicative of inflammation or kidney and liver disease. As a result, this is not the gold standard for diagnosing malnutrition. BUN is also an indicator because urea is the end product of protein metabolism, and when a patient is not getting enough protein, you will see a decreased BUN.

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which steps should the nurse include in the teaching plan? (Select all that apply.) a. Applying a dry sterile dressing b. Cleansing the wound c. Managing pain d. Using cold water in the bath e. Hand washing

B, C, E Administering pain medications will ensure that the patient is comfortable prior to a dressing change. Hands should be washed before and after performing a dressing change. The nurse should show the daughter how to cleanse the wound and then apply the sterile. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? (Select all that apply.) a. Drink plenty of water. b. Eat plenty of foods high in vitamin K. c. Apply sunscreen 30 minutes prior to exposure. d. Wear sunglasses. e. Consume fish oil and vitamin E.

C, D, E Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and is not in a recommendation for the prevention of melanoma.

A nurse is instructing a nursing assistant on how to prevent pressure ulcers for frail elderly clients. The action by the nursing assistant indicates understanding of the instructions? (Select all that apply.) a. Maintains a cooler environment when bathing b. Bathes and dries the skin vigorously to stimulate circulation c. Offers nutritional supplements and frequent snacks d. Keeps the head of the bed elevated 45 degrees e. Turns the patient at least every 2 hours

C, E The patient should be turned at least every 2 hours because permanent damage to the tissues can occur at pressure points in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Elevation of the head of the bed more than 30 degrees and overstimulation of the skin may stimulate, if not actually encourage, dermal decline. Older adults are more prone to hypothermia if bathed in a cooler environment.

A patient 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. Dysrhythmias b. Muscle weakness c. Increased urine output d. Anemia and leukopenia

Dysrhythmias Rationale: A serum potassium level less than 2.5 mEq/L indicates severe hypokalemia, which can lead to life-threatening dysrhythmias (e.g., bradycardia, tachycardia, ventricular dysrhythmias). Other manifestations of potassium deficiency include muscle weakness and renal failure. Patients with anorexia nervosa often have iron-deficiency anemia and an elevated blood urea nitrogen level related to intravascular volume depletion and abnormal renal function.

A malnourished patient has been diagnosed with protein deficiency. Which complications should the nurse anticipate? (Select all that apply.) a. Edema b. Asthma c. Anemia d. Malabsorption syndrome e. Impaired wound healing f. Gastrointestinal bleeding

Edema Anemia Impaired wound healing Rationale: Protein deficiency can cause complications such as edema, anemia, and impaired wound healing. Decreased albumin in the vascular space allows fluids to leak into the interstitial spaces causing edema. Without adequate protein, blood formation is impaired. Adequate protein is required for wound healing. Asthma does not develop due to protein deficiency. A malabsorption syndrome may affect the amount of nutrients that are absorbed causing protein deficiency. Gastrointestinal bleeding is not a complication of protein deficiency.

A patient who has dysphagia after a stroke is receiving enteral nutrition through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into the plan of care? a. Use 30 mL of normal saline to flush the tube every 4 hours. b. Avoid flushing the tube any time the patient is receiving continuous feedings. c. Flush the tube before and after feedings if the patient's feedings are intermittent. d. Flush the PEG with 100 mL of sterile water before and after medication administration.

Flush the tube before and after feedings if the patient's feedings are intermittent. 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.

The patient has parenteral nutrition (PN) infusing with amino acids and dextrose. During shift change, the nurse reports the tubing, bag, and dressing were changed 20 hours ago. What care should the incoming nurse plan to deliver? (Select all that apply.) a. Giving the patient insulin if needed b. Ensuring that the next bag has been ordered c. Checking amount of solution left in the bag d. Assessing the insertion site and change the tubing e. Verifying the accuracy of the new solution and ingredients

Giving the patient insulin if needed Ensuring that the next bag has been ordered Checking amount of solution left in the bag Assessing the insertion site and change the tubing Verifying the accuracy of the new solution and ingredients Rationale: The nurse should identify the amount of PN left in the bag when initiating care and request more if needed. Abrupt withdrawal of PN can cause hypoglycemia. The nurse should anticipate pharmacy preparation of a new bag may take significant time especially if additives are ordered. PN solutions are changed every 24 hours. The label on the bag should be verified with the order to ensure accuracy. The patient would receive insulin if hyperglycemic related to dextrose content parenteral nutrition or underlying diabetes mellitus. Sliding-scale coverage or addition of regular insulin to the parenteral nutrition would be provided if ordered. The insertion site should be monitored, and the tubing changed every 24 hours.

A 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 145 mg/dL b. Serum phosphate level of 1.9 mg/dL c. White blood cell count of 10,000/µL d. Serum potassium level of 4.6 mEq/L

Serum phosphate level of 1.9 mg/dL Rationale: Refeeding syndrome can occur if a malnourished patient is started on aggressive nutritional support. Hypophosphatemia (serum phosphate level <2.4 mg/dL) is the hallmark of refeeding syndrome and could result in 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 (>11,000/µL) could indicate an infection. Normal serum potassium levels are between 3.5 and 5.0 mEq/L.

The nurse is evaluating the nutritional status of a patient undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would best indicate the patient has protein-calorie malnutrition (PCM)? a. Serum transferrin b. Serum prealbumin c. C-reactive protein (CRP) d. Alanine transaminase (ALT)

Serum prealbumin Rationale: In the absence of an inflammatory condition, the best indicator of PCM is prealbumin; prealbumin is a protein synthesized by the liver and indicates recent or current nutritional status. Decreased transferrin levels and elevated liver enzyme levels (ALT) are other indicators that protein is deficient. CRP is increased during inflammation and is used to determine if prealbumin, albumin, and transferrin are decreased related to protein deficiency or an inflammatory process.

The nurse is reviewing the laboratory test results for a patient with metastatic lung cancer who was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. How will the nurse interpret these results? a. The albumin level is normal, so the patient does not have protein malnutrition. b. The albumin level is increased, which is common in patients with cancer who have malnutrition. c. Both the serum albumin and prealbumin levels are reduced, consistent with the diagnosis of malnutrition. d. The serum albumin level is normal, but the low prealbumin level accurately reflects the patient's nutritional status.

The serum albumin level is normal, but the low prealbumin level accurately reflects the patient's nutritional status. 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 about 20 to 22 days. The serum level may lag behind actual protein changes by more than 2 weeks and is therefore not the best indicator of acute changes in nutritional status.

A patient received a small-bore nasogastric (NG) tube after a laryngectomy. Which action has the highest priority before initiating enteral feedings? a. Testing aspirated fluid pH b. Auscultating while instilling air c. Elevating head of bed to 40 degrees d. Verifying NG tube placement with x-ray

Verifying NG tube placement with x-ray Rationale: It is imperative to ensure that an NG tube is in the gastrointestinal 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 distinguish between gastric and respiratory placement of the tube. Although elevating the head of bed at least 30 degrees is necessary to prevent aspiration, placement must first be confirmed before starting feedings.

A patient who cannot afford enough food for her family states she only eats after her children have eaten. At a clinic visit, she reports bleeding gums, loose teeth, and dry, itchy skin. Which vitamin deficiency would the nurse suspect? a. Folic acid b. Vitamin C c. Vitamin D d. Vitamin K

Vitamin C Rationale: This patient is lacking vitamin C as evidenced by the bleeding gums, loose teeth, and dry, itchy skin. Manifestations of folic acid deficiency include megaloblastic anemia, anorexia, fatigue, sore tongue, diarrhea, or forgetfulness. Manifestations of vitamin D deficiency include muscular weakness, excess sweating, diarrhea, bone pain, rickets, or osteomalacia. Manifestations of vitamin K deficiency include defective blood coagulation.