220 chapter 11: nutrition

a nurse delivers a tray of food to an older clients and sets it on the overbed table. The client shows no interest in food, however. Which actions should the nurse take? Select all that apply a) remove the tray from the clients room w/o further comment b) provide the client with crackers and ginger ale c) asses the client for signs of depression d) ask why the client does not want anything to eat on the tray e) administer an antiemetic as prescribed f) consult a dietician of the problem persists

c) asses the client for signs of depression d) ask why the client does not want anything to eat on the tray f) consult a dietician of the problem persists

the nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action is correct? a) insert a stylet resistance is felt, and then gently rotate the stylet until resistance decreases b) mix meat tenderizer with 30 mL of warm water, instill the mixture into the feeding tube, wait 15 min, then flush vigorously c) connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure d) advance the tube no more than 4 in (10cm), auscultate for bowel sounds, and then attempt to aspirate again

c) connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure

a nurse is caring for a client who has been prescribed a clear liquid diet. Which liquid can be included in the clients diet? a) low-fat milk b) orange juice c) tomato soup d) cranberry juice

d) cranberry juice

the nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate? a) encourage client to eat using consistent pace, preventing hot foods from becoming too cool, and cool foods from becoming to warm b) create a positive social environment by asking the client about childhood food memories c) arrange food items in a clock face pattern, and tell client which time on clock corresponds to each food item d) speak to the client but limit the need for the client to respond verbally while chewing and swallowing

d) speak to the client but limit the need for the client to respond verbally while chewing and swallowing

a nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube? a) radiographic confirmation of position b) green fluid with particles aspirated c) off-white fluid aspirated d) confirmation that pH of the aspirate is less than 5.5

a) radiographic confirmation of position

the charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse? a) the new nurse places the client in the left lateral recumbent position b) the new nurse interrupts the feeding every 4 hours and aspirates gastric contents c) the new nurse asks the client whether nausea or abdominal pain is present d) the new nurse changes gloves before preparing the feeding bag

a) the new nurse places the client in the left lateral recumbent position *the client should be elevated 30-45 degrees*

the nurse prepares to provide gastrostomy insertion site care. The gastrostomy tube was placed this week. The client reports pain at the site. Which action does the nurse take next? a) clean around the insertion site b) administer pain medication c) provide for client privacy d) assemble bedside equipment

b) administer pain medication *client will better tolerate care after analgesic administration*

the nurse is caring for a client who has a percutaneous endoscopic gastrostomy tube inserted earlier that day. The sutures are still in place. Which interventions should the nurse plan to perform? Select all that apply. a) gently rotate the external bumper 90 degrees once during the shift b) administer prescribed analgesics, as needed c) gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline d) avoid placing tension on the feeding tube e) place the dressing between the skin and external bumper f) measure the length of the exposed tube and compare it with the length documented after insertion

b) administer prescribed analgesics, as needed c) gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline d) avoid placing tension on the feeding tube f) measure the length of the exposed tube and compare it with the length documented after insertion

a nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. On inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next? a) gently rotate the external bumper 90 degrees b) apply gentle pressure to the tube while pressing the external bumper closer to the skin c) apply a skin barrier to the insertion site d) notify the health care provider

b) apply gentle pressure to the tube while pressing the external bumper closer to the skin

a nurse enters a clients room to perform a tube feeding. Which nursing action should be performed first? a) check gastric residual b) aspirate stomach contents and check pH c) pour a premeasured amount of tube feeding formula into the nasogastric tube d) flush the nasogastric tube with the ordered amount of water

b) aspirate stomach contents and check pH *placement should be checked-> gastric residual-> flushed-> administer feeding

a client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take? a) chop the clients food to make it easier to swallow b) check the medical record for the clients prescribed diet c) offer the client a sip of liquid in between each bite d) replace the clients meal tray with soft foods available on the unit

b) check the medical record for the clients prescribed diet

a client with dysphagia prepares to eat dinner. How does the nurse best help this client? a) prepare the foods on the clients tray b) ensure the head of the bed is high-fowler c) play the clients favorite music or video d) converse with the client during the meal

b) ensure the head of the bed is high-fowler

prior to allowing a client to eat, which action is most important for the nurse to take? a) check the clients cultural preferences b) determine if the client has physical limitations c) assess the clients level of consciousness d) determine if the client has eye glasses

c) assess the clients level of consciousness

the nurse is caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action would be most appropriate to address this concern? a) apply a skin barrier to the insertion site b) administer an antibiotic as prescribed c) notify the health care provider for a prescription to apply an anti-fungal powder d) apply gentle pressure to the tube while pressing the external bumper closer to the skin

c) notify the health care provider for a prescription to apply an anti-fungal powder *if skin has patchy, red rash, the cause could be candidiasis (yeast)

the nurse performs gastrostomy site care and notes drainage. Which action does the nurse take next? a) clean the site with hydrogen peroxide b) administer an antibiotic ointment to the site c) place the drain sponge under the external bumper d) notify the health care provider

c) place the drain sponge under the external bumper *drainage is normal finding, sponge/gauze is placed around tube for comfort and prevent irritation

the nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method should the nurse use to increase the flow rate of the formula? a) using the plunger of the syringe, steadily infuse the formula over the desired period of time b) ask the client to bear down while the formula is infusing c) attach the syringe to a syringe pump and set the infusion rate to 250 mL/hr d) raise the heigh of the syringe

d) raise the heigh of the syringe *syringe feedings are infused via gravity*

a nurse has just received a clients laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption? a) hemoglobin 11.3 g/dL (113 g/L) b) creatinine 1.9 mg/dL (168 umol/L) c) hematocrit 56% (0.56) d) serum albumin 2.8 g/dL (28 g/L)

d) serum albumin 2.8 g/dL (28 g/L)

A nurse is assessing a clients nutritional status. Which findings should lead the nurse to suspect poor nutritional status?

flaky facial skin, facial edema, and pale skin color