2) Chapter 63 Care of Patients with Malnutrition and Obesity

An older client admitted to the hospital from the nursing home refuses to eat anything on her meal tray. What instructions will the nurse give to the nursing assistant who is attempting to feed the client? Select all that apply. A. "Feed her the soft food because she has no teeth." B. "Place the fork in her hand and leave the room." C. "Sit at her level so that she can feel more comfortable." D. "Take your time feeding her and don't rush her." E. "Offer her the Ensure supplement instead of feeding her." F. "Ask the client what foods she likes and dislikes."

A. "Feed her the soft food because she has no teeth." C. "Sit at her level so that she can feel more comfortable." D. "Take your time feeding her and don't rush her." F. "Ask the client what foods she likes and dislikes." Rationale The client does not have any teeth to chew food, so to prevent choking, the nursing assistant should feed her only soft food that does not require chewing. Sitting face to face with or at the same level of the client can help make her feel comfortable during mealtimes, thus providing more support and possibly resulting in the client choosing to eat. The nursing assistant should also take her time while feeding the client for safety reasons and to support the client. Individuals are more likely to eat when given a choice in food selections that consider their likes and dislikes. A client who refuses to eat will not likely eat when left alone. Also, if the client is confused or disoriented, a fork may be dangerous. A balanced nutrition meal should be encouraged before using supplements.

An RN who usually works on the pediatric unit is floated to the GI medical-surgical unit. Which client is appropriate for the charge nurse to assign to the float nurse? A. 20-year-old with anorexia nervosa receiving total parenteral nutrition (TPN) through a central venous line B. 35-year-old who had a laparoscopic gastroplasty yesterday and is now taking sips of clear liquids C. 60-year-old with gastric cancer receiving elemental feedings through a jejunostomy tube D. 65-year-old with morbid obesity who requires a preoperative bariatric surgery assessment

A. 20-year-old with anorexia nervosa receiving total parenteral nutrition (TPN) through a central venous line Rationale A. A pediatric nurse would be familiar with the pathophysiology and collaborative treatment of the client with anorexia nervosa. B. The client with a laparoscopic gastroplasty requires more familiarity with adult nutritional disorders and bariatric surgery. C. The client with gastric cancer receiving elemental feedings through a jejunostomy tube requires more familiarity with adult nutritional disorders and bariatric surgery. D. The client with morbid obesity who requires a preoperative bariatric surgery assessment requires more familiarity with adult nutritional disorders and bariatric surgery.

Which morbidly obese client is not a candidate for bariatric surgery? A. 34-year-old woman experiencing mental confusion B. 44-year-old man with a history of hypertension C. 50-year-old woman with a history of sleep apnea D. 52-year-old man with a history of type 1 diabetes mellitus

A. 34-year-old woman experiencing mental confusion Rationale A. The client who is experiencing mental confusion is not a good candidate for bariatric surgery because the client may have difficulty complying with the postoperative treatment regimen.

How does a nurse accurately calculate a client's body mass index (BMI)? A. BMI = weight (kg)/height (in meters)2 B. BMI = weight (lb)/height (in inches)2 C. BMI = weight (kg)/height (in meters) D. BMI = weight (lb)/height (in meters)

A. BMI = weight (kg)/height (in meters)2

A nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take in the event that the client develops fever, increased triglycerides, and clotting problems? A. Discontinues the IVFE infusion B. Documents the findings and continues to monitor C. Slows the rate of flow of the IVFE infusion D. Switches the infusion to total parenteral nutrition (TPN) infusion

A. Discontinues the IVFE infusion Rationale A. For clients receiving fat emulsions, monitor for manifestations of fat overload syndrome, especially in those who are critically ill. These manifestations include fever, increased triglycerides, clotting problems, and multi-system organ failure. Discontinue the IVFE infusion, and report any of these changes to the health care provider immediately if this complication is suspected. B. Documenting the findings and continuing to monitor will have serious repercussions for this client. The IV must be stopped. C. Slowing the rate of flow of the IVFE infusion will present a serious safety risk for the client. The IVFE needs to be stopped. D. Nurses do not request IV parenteral therapies or change them unless the health care provider makes the decision.

A nurse is instructing a group of overweight clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle changes does the nurse emphasize? Select all that apply. A. "Begin a weight-training program for building muscle mass." B. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." C. "Eat a variety of foods, especially grain products, vegetables, and fruits." D. "Engage in moderate physical activity for at least 30 minutes each day." E. "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." F. "Liquid dietary supplements can be substituted safely for solid food while attempting to lose weight."

B. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." C. "Eat a variety of foods, especially grain products, vegetables, and fruits." D. "Engage in moderate physical activity for at least 30 minutes each day." E. "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." Rationale A weight-training program for building muscle mass does not need to be included in a weight loss program. Muscle weighs more and tends to increase weight in people who weight-train.

A malnourished client is being discharged on enteral nutrition products. Which suggestion from the registered dietitian does the nurse implement to make the enteral feeding experience more normal for the client? A. Administering the feeding product on a regular schedule B. Bringing the enteral product and napkin to the client on a tray C. Emphasizing the need to take iron medications before the feeding D. Once feeding is completed, putting equipment out of view

B. Bringing the enteral product and napkin to the client on a tray Rationale A. Although the feeding product should be administered according to the prescribed schedule, this will not necessarily normalize the experience for the client. B. "Serving" the enteral product and napkin on a tray will help normalize the feeding experience for the client. C. Although iron medications may be helpful in preventing constipation, encouraging their use will not normalize the experience for the client. D. Although putting equipment away after use may be helpful in taking the client out of the dependent "client" role, this will not serve to normalize the feeding experience itself.

A client has a primary problem of inadequate nutrition caused by the effects of chemotherapy. The client is receiving continuous enteral feedings through a nasogastric tube (NG) tube. What does the RN ask the LPN/LVN to do for this client? A. Assess nutritional parameters on the client every 3 days. B. Check the residual volume of the NG tube every 4 hours. C. Monitor the client for signs and symptoms of pneumonia. D. Teach the client about the purpose of enteral feedings.

B. Check the residual volume of the NG tube every 4 hours.

The client is an older adult with severe rheumatoid arthritis in the upper extremities. On assessment, the nurse determines that the client is malnourished. What does the nurse suspect as the cause for this client's malnutrition? A. A decrease in the client's appetite B. Decreasing ability to manipulate eating utensils C. Inadequate income to purchase sufficient food D. Metabolic requirements that are increased owing to immobility

B. Decreasing ability to manipulate eating utensils Rationale A. No evidence suggests that the client is experiencing a decrease in appetite. B. The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils. C. No evidence suggests that the client is financially unable to purchase adequate food. D. No evidence suggests that the client is immobile because of osteoarthritis in the extremities. Metabolic requirements would decrease with less mobility.

Situation: A 45-year-old obese woman with a body mass index (BMI) of 30 has high blood pressure. After a complete physical examination, her health care provider places her on a diuretic and also prescribes orlistat (Xenical) 60 mg orally three times a day. She takes this medication for 4 weeks, losing only 10 pounds. The health care provider doubles the amount of Xenical and recommends behavioral changes. A nurse is teaching the client appropriate behavioral changes. What is included in the teaching plan? Select all that apply. A. Cognitive restructuring to learn negative coping statements B. Keeping a daily food diary C. Identifying emotional and situational factors that stimulate eating D. Increasing exercise E. Seeking behaviors in others that one can model

B. Keeping a daily food diary C. Identifying emotional and situational factors that stimulate eating D. Increasing exercise Rationale Cognitive restructuring involves modifying negative beliefs by learning positive coping self-statements.

A client is receiving nutritional supplements to restore nutritional status. What does the nurse do to assess the effectiveness of the supplements for the client? A. Keeps an accurate and precise food and fluid intake record daily B. Makes certain the client is weighed daily at the same time C. Monitors vital signs every 4 hours and as needed D. Weekly assesses the client's skin for evidence(s) of breakdown

B. Makes certain the client is weighed daily at the same time Rationale A. Although it is important to identify everything that the client is taking in orally, this does not help assess the effects of nutritional supplements on the client. B. Daily weigh-ins will best show the effects of nutritional supplements by showing how much weight the client is regaining. C. Although monitoring of vital signs is important, it does not help assess the effects of nutritional supplements on the client. D. Although it is important to identify any evidence of skin breakdown, this does not directly help in assessing the effects of nutritional supplements on the client.

A nurse is teaching a group of adults in the community about the most recent Dietary Guidelines for Americans (2010). What does the nurse include with respect to the consumption of alcohol? A. Men should limit their drinking to 1 drink per day. B. Men may have 2 drinks every day. C. Older adults should have only 1 drink each week. D. Women should be limited to 2 drinks a day.

B. Men may have 2 drinks every day. Rationale A. The Guidelines indicate that men may have 2 drinks a day. B. The most recent guidelines (2010) emphasize the need to include preferences of specific racial/ethnic groups, vegetarians, and other populations when selecting foods to maintain a healthful diet that is balanced with moderation and variety. If alcohol is consumed, it should be limited to 1 drink per day for women and 2 drinks per day for men. C. The Guidelines do not differentiate recommendations with respect to age. D. Women should have 1 alcoholic drink every day.

Situation: A 45-year-old obese woman with a body mass index (BMI) of 30 has high blood pressure. After a complete physical examination, her health care provider places her on a diuretic and also prescribes orlistat (Xenical). She asks the nurse how Xenical works. How does the nurse respond? A. "It decreases the amount of norepinephrine in your brain. This action will increase your feeling of being satisfied on less food." B. "It increases the amount of serotonin in your brain. This action will greatly increase your metabolic rate, and you will burn calories quicker." C. "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." D. "It will alter the chemistry of your brain. Consequently, you will feel full before you overeat."

C. "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." Rationale A. Orlistat does not decrease the amount of norepinephrine in the brain. B. Orlistat does not increase the amount of serotonin in the brain. C. Orlistat inhibits lipase and leads to partial hydrolysis of triglycerides. Because fats are only partially digested and absorbed, calorie intake is decreased. D. Orlistat does not alter the chemistry of the brain.

A nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" about what the BMI number means. Which client statement indicates a need for further instruction? A. "If I could get my BMI below 25, my risk for malnutrition would decrease." B. "I realize that this means that I have some increased health risks." C. "My goal should be to get my BMI below 18.5." D. "This means that I have an increased amount of total fat stored in my body."

C. "My goal should be to get my BMI below 18.5." Rationale A. The lowest risk for malnutrition is for the adult client whose BMI is between 18.5 and 25. Older adults should have a BMI between 23 and 27. B. The client with a BMI greater than 24.9 has increased health risks that a client with a lower number would not have. C. The least risk for malnutrition is actually seen in adult clients whose BMI is between 18.5 and 25. D. The client's BMI of 27.5 does mean that an increased amount of fat is stored in the body in relation to the client's height.

A female client is concerned that her inability to conceive a child is connected to her morbid obesity. How does the nurse respond? A. "Do you feel that your obesity is keeping you from getting pregnant?" B. "Have you considered adoption as an option?" C. "Tell me about changes, if any, in your menstrual cycle each month." D. "What has your health care provider told you about your problems in getting pregnant?"

C. "Tell me about changes, if any, in your menstrual cycle each month." Rationale A. The response only asks the client to restate the obvious. It is also a closed question that requires only a "yes" or "no" response. B. This is an intrusive response by the nurse and may alienate the client. It also does not address the client's concern about obesity. C. Obesity has been known to produce changes in the menstrual cycle, thus causing difficulties in getting pregnant. D. This is an evasive response from the nurse and does not address the client's concerns.

A nurse is performing a health assessment on an obese client. The client states, "I have tried many diets in an effort to lose weight but have been unsuccessful!" How does the nurse assess whether the client's response to stress is related to the client's obesity? A. "Do you have a history of mental problems, especially depression?" B. "Do you usually use alcohol or drugs when you feel stressed?" C. "Tell me what you do to relieve stress in your daily life." D. "What is it about your obesity that causes you to feel uncomfortable?"

C. "Tell me what you do to relieve stress in your daily life." Rationale A. This question will cause the client to feel uncomfortable with the assessment. Problems in handling stress do not mean mental health or depression problems. B. This question could cause the client to feel uncomfortable with the assessment. More effective methods can be used to determine the client's alcohol and drug habits. C. This is the only question that allows the client to verbalize stress-relieving mechanisms. It is also a question that cannot be answered with a simple "yes" or "no." D. This question will only cause the client to restate the obvious. It does not determine the effect that stress has on the client.

A nurse is teaching a class of older adults in the community about engaging in "regular" exercise. What does the nurse advise them? A. "1 to 2 hours of cardiovascular exercise every day is a good idea." B. "Joining a fitness program or gym will help greatly with your exercise." C. "Walking 20 minutes provides the same benefit as long periods of exercise." D. "You will benefit most if you get into a group that shares your exercise goals."

C. "Walking 20 minutes provides the same benefit as long periods of exercise." Rationale A. 1 to 2 hours of cardiovascular exercise every day is not required to achieve benefits of exercise. B. A fitness program or gym is not necessary to achieve a regular exercise workout. It is expensive, and many older adults have a fixed income and cannot afford memberships. C. Although some people think that regular exercise has to include joining a fitness program or exercising for long periods of time, simple forms of exercise like walking 20 minutes provide the same type of benefit. Older adults can engage in this type of exercise. It does not cost money (like joining a program) and provides health benefits such as strengthening joints and improving cardiovascular health. D. A 20-minute walk can be accomplished with a group (such as "mall walking") or alone. Some people like and want to have this time to themselves.

A client receiving total parenteral nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the client most likely experiencing? A. Calcium imbalance B. Fluid volume deficit C. Fluid volume overload D. Potassium imbalance

C. Fluid volume overload Rationale A. This client's symptoms are not indicative of calcium imbalance. B. This client's symptoms are not indicative of fluid deficit. C. Congestive heart failure and pulmonary edema are symptoms of fluid overload. D. This client's symptoms are not indicative of potassium imbalance.

A client is placed on orlistat (Xenical) as part of a treatment regimen for morbid obesity. What side effects does the nurse tell the client to expect from using this drug? A. Dry mouth, constipation, and insomnia B. Insomnia, dry mouth, and blurred vision C. Loose stools, abdominal cramps, and nausea D. Palpitations, constipation, and restlessness

C. Loose stools, abdominal cramps, and nausea Rationale A. These are not side effects of Xenical. B. These are side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate, Tenuate Dospan), and phendimetrazine (Bontril). C. These are side effects unique to orlistat (Xenical). D. These are side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate, Tenuate Dospan), and phendimetrazine (Bontril).

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse effectively plan nutritional care for this client? A. Calculates his body mass index (BMI) B. Keeps a 24-hour diary of his physical activities C. Maintains a 24-hour recall (diary) of his food intake D. Obtains his accurate height and weight measurements

C. Maintains a 24-hour recall (diary) of his food intake Rationale A. Although calculating a BMI is an important part of a nutritional assessment, it does not address the issue of the client's food preferences. B. Keeping an activity diary will not reveal any information related to the client's food preferences. C. Maintaining a 24-hour recall of food intake will determine the client's food preferences and eating patterns so that they can be incorporated into the diet to the greatest extent possible. D. Although measuring height and weight is an important part of a nutritional assessment, it does not address the issue of the client's food preferences.

A nurse manager in a long-term care facility plans nutritional assessments of all residents. Which nutritional assessment activity does the nurse delegate to unlicensed assistive personnel (UAP) at the facility? A. Assessing residents' abilities to swallow B. Determining residents' functional status C. Measuring the daily food and fluid intake of residents D. Screening a portion of the residents with the Mini Nutritional Assessment

C. Measuring the daily food and fluid intake of residents Rationale A. Assessing residents' abilities to swallow requires broad knowledge of normal physiology, nutrition, and factors that impact on nutrition and should be done by licensed nursing staff. B. Determining residents' functional status requires broad knowledge of normal physiology, nutrition, and factors that impact on nutrition and should be done by licensed nursing staff. C. UAP education includes measurement of clients' oral intake; this skill does not require clinical judgment to be completed accurately. D. Screening with the Mini Nutritional Assessment requires broad knowledge of normal physiology, nutrition, and factors that impact on nutrition and should be done by licensed nursing staff.

Situation: An 87-year-old woman resident from an extended-care facility has not been eating for several days. She is admitted to the hospital with a diagnosis of malnutrition. She has an enteral feeding tube placed in her left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel). She has developed a severe case of diarrhea. What is a possible cause? A. Digoxin (Lanoxin) B. Gastritis C. Potassium chloride (Kay Ciel) D. Ranitidine (Zantac)

C. Potassium chloride (Kay Ciel) Rationale A. Diarrhea is not a frequent side effect of digoxin. B. Gastritis does not cause diarrhea. The other signs and symptoms of gastritis are not mentioned in this scenario. C. In some cases, diarrhea may be the result of liquid medications such as elixirs and suspensions that have a very high osmolality. D. Diarrhea is not a frequent side effect of ranitidine.

Situation: An 87-year-old woman resident from an extended-care facility has not been eating for several days. She is admitted to the hospital with a diagnosis of malnutrition. She has an enteral feeding tube placed in her left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel). The nurse who is responsible for checking the gastric pH of the feeding tube tests it and obtains a value of 6.0. This finding may indicate that the feeding tube is in the client's lungs. Is there another possible explanation for the nurse to consider? A. No. The feeding tube must be removed. B. No. The potassium effect will prevent the pH from reaching 6.0. C. Yes. The client is taking Zantac. D. Yes. The pH paper has expired and is giving a false reading.

C. Yes. The client is taking Zantac. Rationale A. This finding—given the circumstances—does not mean that the tube is displaced and in the client's lungs. B. The potassium effect does not cause the pH to become more alkaline. C. The pH may be as high as 6.0 if the client takes certain medications, such as H2 blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]). D. Expired pH paper will provide no data that are reliable, so it would be impossible to have a reading of "6."

Which client on a medical-surgical unit does the charge nurse assign to the LPN/LVN? A. 28-year-old with morbid obesity who had bariatric surgery today B. 30-year-old recently admitted with severe diarrhea and Clostridium difficile infection C. 36-year-old whose family needs instruction about how to use a gastric feeding tube D. 39-year-old with a jejunal feeding tube who needs elemental feedings administered

D. 39-year-old with a jejunal feeding tube who needs elemental feedings administered Rationale A. Initial assessment of a postoperative client requires RN education and scope of practice. B. Initial assessment of a new admission requires RN education and scope of practice. C. Client and family teaching requires RN education and scope of practice. D. LPN/LVN education includes administration of tube feedings and associated client care and monitoring.

Which serum albumin level does the nurse expect to see in the healthy, ambulatory older adult client? A. 3.3 g/dL B. 3.7 g/dL C. 3.9 g/dL D. 4.3 g/dL

D. 4.3 g/dL

An RN receives the change-of-shift report about these clients. Which client does the nurse assess first? A. 30-year-old admitted 2 hours ago with malnutrition that is associated with malabsorption syndrome B. 45-year-old who had gastric bypass surgery and is reporting severe incisional pain C. 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL D. 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min

D. 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min Rationale A. The client admitted 2 hours ago with malnutrition needs assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority. B. The client who had gastric bypass surgery and is reporting severe incisional pain needs assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority. C. The client receiving TPN with a BG level of 300 mg/dL needs assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority. D. Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. This client needs respiratory assessment and interventions immediately.

Situation: A 45-year-old obese woman with a body mass index (BMI) of 30 has high blood pressure. After a complete physical examination, her health care provider places her on a diuretic and also prescribes orlistat (Xenical) 60 mg orally three times a day. She has been taking this medication for 4 weeks and has lost only 10 pounds. What does the nurse anticipate the health care provider will do for this client? A. Change her medication to phendimetrazine (Bontril). B. Decrease the amount of her medication. C. Encourage her to decrease her activity level. D. Increase the dosage of her medication.

D. Increase the dosage of her medication. Rationale A. Phendimetrazine (Bontril) is a sympathomimetic drug that suppresses appetite for short-term use along with a structured weight management and exercise program. It acts on the central nervous system, including suppressing the appetite center in the hypothalamus. Clients with hypertension should not take this drug. B. The medication is being given at a low dose—60 mg. Decreasing it would make weight loss occur more slowly. C. All diet plans include an increase in physical activity. Having the client decrease her activity level would make her weight loss more gradual. D. The usual dosage can be 120 mg three times a day, depending on the client's response.

Which nursing care activity for a malnourished client does the nurse safely delegate to unlicensed assistive personnel (UAP)? A. Completing the Mini Nutritional Assessment B. Determining body mass index (BMI) C. Estimating body fat using skin-fold measurements D. Measuring current height and weight

D. Measuring current height and weight Rationale A. The nurse is responsible for completing the Mini Nutritional Assessment. B. The nurse is responsible for determining the client's BMI. C. The nurse is responsible for estimating body fat using skin-fold measurements. D. Determining height and weight is the only activity that can be safely delegated to UAP.

An older adult client needs additional dietary protein but refuses to drink the prescribed liquid protein supplements. Which nursing intervention is most effective in increasing the client's protein intake? A. Administering the liquid supplement with routine medications B. Giving a glucose polymer modular supplement C. Keeping a food and fluid intake diary for at least 3 days D. Providing protein modular supplements in the form of puddings

D. Providing protein modular supplements in the form of puddings Rationale A. This approach will not be effective because the client has already refused to drink the liquid supplements. B. Glucose polymer modular supplements will increase the client's calorie intake but not protein intake. C. A food and fluid diary will provide information about the client's typical intake pattern but will not increase protein intake. D. Providing protein modular supplements in the form of puddings would increase the client's protein intake in an alternate format, other than a liquid supplement.

A client has undergone bariatric surgery. Which nursing intervention is the highest priority in preventing dehydration in this client? A. Ambulating the client as quickly as possible after surgery B. Applying an abdominal binder daily when the client is out of bed C. Observing for tachycardia, nausea, diarrhea, and abdominal cramping D. Providing six small feedings daily; offering fluids frequently

D. Providing six small feedings daily; offering fluids frequently Rationale A. Ambulation will prevent pulmonary embolism and other circulatory problems, but not dehydration. B. An abdominal binder will help support the abdomen and may prevent dehiscence of the wound, but not dehydration. C. Observing for these signs will prevent the development of postoperative dumping syndrome, but not dehydration. D. Small daily feedings and adequate fluids will prevent the development of dehydration in the client after bariatric surgery.

A client is discharged home with an enteral feeding tube. What does the home health nurse do to determine the patency of the client's enteral tube? A. Arranges for the client to have an x-ray performed periodically B. Auscultates the client's abdomen for bowel sounds before each feeding C. Instills air into the tube to check for placement and patency before each feeding D. Tests aspirated tube contents for pH level before each feeding

D. Tests aspirated tube contents for pH level before each feeding Rationale A. The client should have an x-ray performed when the enteral tube is initially inserted. B. The presence of bowel sounds does not indicate that the enteral tube is in place. C. This traditional auscultatory method for checking enteral tube placement is not reliable, especially for the client with a small-bore tube. D. This is considered to be the most accurate method for confirming enteral tube placement.

A client who is receiving total enteral nutrition (TEN) exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begins to have a generalized seizure, how does the nurse interpret this client's signs and symptoms? A. The enteral tube is misplaced or dislodged. B. Abdominal distention is present. C. A fluid and electrolyte imbalance is present. D. This is refeeding syndrome.

D. This is refeeding syndrome. Rationale A. If the enteral tube becomes misplaced or dislodged, the client may develop aspiration pneumonia displayed by increased temperature, increased pulse, dehydration, diminished breath sounds, and shortness of breath. B. Abdominal distention is most frequently accompanied by nausea and vomiting. C. Signs and symptoms of fluid and electrolyte problems resulting in circulatory overload can include peripheral edema, sudden weight gain, crackles, dyspnea, increased blood pressure, and bounding pulse. D. Symptoms of refeeding syndrome include shallow respirations, weakness, acute confusion, seizures, and increased bleeding tendency.

A nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? A. Bowel sounds are not audible in all quadrants. B. Client's skin under the panniculus is excoriated. C. The client reports pain when being repositioned. D. Urine output total is 15 mL for the past 2 hours.

D. Urine output total is 15 mL for the past 2 hours. Rationale A. Inaudible bowel sounds may require nursing interventions but do not require immediate intervention by the surgeon. On the day of surgery, they will probably be absent normally for some time. B. Excoriated skin under the panniculus may require nursing interventions but does not require immediate intervention by the surgeon. C. Subjective reports of pain may require nursing interventions but do not require immediate intervention by the surgeon, as does the scant urine output. D. Oliguria may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure.

A bariatric client is recuperating after injury. Which nursing intervention most effectively prevents injury to the client who is being repositioned postoperatively? A. Administering pain medication B. Making sure to not move the client's nasogastric (NG) tube C. Monitoring skin-fold areas and keeping them clean and dry D. Using a weight-rated extra-wide bed for the client

D. Using a weight-rated extra-wide bed for the client Rationale A. Although pain medication will add to the comfort of the client, it will not prevent injury to the client that might occur during repositioning. B. Not moving the client's NG tube will prevent disruption of the suture line but will not prevent injury to the client that might occur during repositioning. C. Monitoring skin-fold areas will prevent the development of skin breakdown but will not prevent injury to the client that might occur during repositioning. D. Using a special bed will allow adequate room for repositioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury.

Based on nutritional screening findings and assessments, which client will be most successful with surgical treatment for obesity? A. Man with a BMI of 40, weight 75% above ideal body weight B. Man with a BMI of 41, weight 80% above ideal body weight C. Woman with a BMI of 38, weight 50% above ideal body weight D. Woman with a BMI of 42, weight 100% above ideal body weight Based on nutritional screening findings and assessments, which client will be most successful with surgical treatment for obesity? A. Man with a BMI of 40, weight 75% above ideal body weight B. Man with a BMI of 41, weight 80% above ideal body weight C. Woman with a BMI of 38, weight 50% above ideal body weight D. Woman with a BMI of 42, weight 100% above ideal body weight

D. Woman with a BMI of 42, weight 100% above ideal body weight Rationale A. This client does not have a high enough BMI-to-weight ratio to be considered for surgical intervention. B. This client does not have a high enough BMI-to-weight ratio to be considered for surgical intervention. C. This client does not have a high enough weight to be considered for surgical intervention. D. The best candidate for surgical intervention is the one with a BMI of 40 or more and a weight 100% above the ideal body weight.