Chapt. 60

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 This client is most likely experiencing fluid volume overload. CHF and pulmonary edema are symptoms of this condition.Calcium imbalance, fluid volume deficit, and potassium imbalance do not manifest with CHF and pulmonary edema.

1. A client weighs 228 pounds (103.6 kg) and is 53 (160 cm) tall. What is this clients body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.) _____

40.4 Using the formula : , or 40.4 rounded up to the nearest tenth.

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. Do you have a one- or two-story home? b. Can you check your own pulse rate? c. Do you have any alcohol in your home? d. Can you prepare your own meals?

ANS: A A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this clients safety.

7. To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection

ANS: A Clients receiving PPN typically get large amounts of fluid volume, making the client with heart failure a poor candidate. The other candidates are appropriate for this type of nutritional support.

A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond? a. Bile salts accumulate in the skin and cause the itching. b. Toxins released from an inflamed gallbladder lead to itching. c. Itching is caused by the release of calcium into the skin. d. Itching is caused by a hypersensitivity reaction.

ANS: A In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.

A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the clients formula. c. Dilute the clients formula. d. Slow the rate of infusion.

ANS: A Proteins and sugar molecules in the enteral feeding product contribute to dehydration due to increased osmolarity. The nurse can administer free-water boluses after consulting with the provider on the appropriate amount and timing of the boluses, or per protocol. The client may not be able to switch formulas. Diluting the formula is not appropriate. Slowing the rate of the infusion will not address the problem.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. Its a good thing I love orange and cherry gelatin. b. My spouse will be here to drive me home. c. I should refrigerate the GoLYTELY before use. d. I will buy a case of Gatorade before the prep.

ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didnt know it would be this hard to live like this. What response by the nurse is best? a. Assess the clients coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.

ANS: A The nurse should assess this clients coping styles and support systems in order to provide holistic care. The other options do not address the clients distress.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the clients oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.

ANS: A This client has clinical indicators of dehydration, so the nurse calculates the clients 24-hour intake, output, and fluid balance. This information is then reported to the provider. The clients oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The clients dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action.

1. A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

ANS: A This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.

A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. Increase the fiber and water in your diet. b. Reduce fat to less than 30% each day. c. Report dry mouth and decreased sweating. d. Lorcaserin may cause loose stools for a few days.

ANS: A This drug can cause constipation, so the client should increase fiber and water in the diet to prevent this from occurring. Reducing fat in the diet is important with orlistat. Lorcaserin can cause dry mouth but not decreased sweating. Loose stools are common with orlistat.

When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks.

ANS: A, B, C, E Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty snacks are not recommended because all adults should limit sodium in their diets.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages

ANS: A, C, D, E Many factors increase the hospitalized clients risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill clients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume the snacks are leading to malnutrition.

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider

ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%

ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.

A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL

ANS: B A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. Drinking at least 2 liters of water each day is suggested. b. I will decrease the amount of fatty foods in my diet. c. Drinking fluids with my meals will increase bloating. d. I will avoid concentrated sweets and simple carbohydrates.

ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.

A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating quiet time so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse

ANS: B All actions are good for client comfort, but when dealing with an obese client, the staff should take extra precautions, such as ensuring the siderails are not putting pressure on the clients tissues. The other options are appropriate for any client, and are not specific to obese clients.

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the clients record because I just have to know how much she weighs! What action by the clients nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State That is a violation of client confidentiality. c. Tell the nurse Dont look; Ill tell you her weight. d. Walk away and ignore the other nurses behavior.

ANS: B Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.

A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours. d. Weigh the client daily on the same scale.

ANS: B For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met.

A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the clients readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.

ANS: B Many hospitals that see bariatric-sized clients have appropriate equipment for this population. A hospital that does not typically see these clients is less likely to have appropriate equipment, putting staff and client safety at risk. The nurse ensures enough staffing is available to help with all aspects of mobility. It may or may not be appropriate to assess the clients willingness to make lifestyle changes. Leaving the siderails down may present a safety hazard. The staff should be sensitive to this clients situation, but safety takes priority.

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

ANS: B Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowlers position with the head of bed elevated.

ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

A clients small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.

ANS: B, C, E If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula.

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach

ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

ANS: B, D, E Some of the goals in this initiative include increasing fruit consumption to 0.9 cups/1000 calories, increasing vegetable intake to 1.1 cups/1000 calories, increasing the number of people at a healthy weight by 10%, decreasing the number of adults who are obese by 10%, and reducing the consumption of saturated fats by 9.5%.

5. A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the clients pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.

ANS: C All actions are appropriate care measures for this client; however, airway is always the priority. Bariatric clients tend to have short, thick necks that complicate airway management.

A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1 F (37.8 C) b. Positive Murphys sign c. Light-colored stools d. Upper abdominal pain after eating

ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.

A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? a. Deficit of calories b. Lack of all nutrients c. Specific lack of protein d. Unknown cause of malnutrition

ANS: C Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition.

A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.

ANS: C Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The capsules can be opened and the powder sprinkled on applesauce if needed. b. I will wipe my lips carefully after I drink the enzyme preparation. c. The best time to take the enzymes is immediately after I have a meal or a snack. d. I will not mix the enzyme powder with food or liquids that contain protein.

ANS: C The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.

ANS: C The nurse should complete a variance report per agency policy. Asking another nurse to help and requesting better equipment are both good ideas, but the nurse may have an injury that needs care. It would be unethical to refuse to care for this client again.

A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the clients gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half.

ANS: C The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse should not continue to feed the client while he or she is vomiting

A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L

ANS: C The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this client first. The blood glucose reading is high, but not extreme. The sodium is normal. The client with the diarrhea should be seen last to avoid cross-contamination.

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight

ANS: C While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the clients psychosocial status as the priority.

A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesnt get spoiled. b. Assess the clients mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

ANS: C, D, E The UAP should make sure food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The UAP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse.

A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this clients height? a. Add the trunk and leg measurements. b. Ask the client how tall he or she is. c. Estimate by measuring clothing. d. Use knee-height calipers.

ANS: D A sliding blade knee-height caliper is used to obtain the height of a client who cannot stand upright, such as those with kyphosis or lower extremity contractures. The other methods will not yield accurate data.

A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygie

ANS: D Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose is also an important measure, but preventing infection takes priority. The IV dressing is changed every 48 to 72 hours. TPN does not need to be double-checked with another nurse.

After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. All weight-loss drugs can cause suicidal ideation. b. No drugs are currently available for weight loss. c. Only over-the-counter medications are available. d. There are three drugs currently approved for this.

ANS: D There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine- topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation.

An older client is at risk for malnutrition. Which nursing intervention is most appropriate to ensure optimum nutritional intake? a. Assisting the client with toileting and oral care prior to meals b. Turning on the television during meals to provide distraction c. Reminding UAPs to allow the client to remain in bed during meals

Assisting the client with toileting and oral care prior to meals The most appropriate intervention to ensure optimum nutritional intake in an older client at risk for malnutrition is to assist the client. Clients need to be assisted with toileting and oral care prior to meals for comfort and to prevent these from distracting clients from meals.Antiemetics and analgesics should be provided prior to meals. Clients need to be free from distractions while eating. When possible, clients would be placed in chairs for eating.

Which morbidly obese client is the least likely candidate for bariatric surgery? a. A 34-year-old woman experiencing mental confusion b. A 44-year-old man with a history of hypertension c. A 50-year-old woman with a history of sleep apnea d. A 52-year-old man with a history of type 1 diabetes mellitus

a. A 34-year-old woman experiencing mental confusion The least likely candidate is the client who is experiencing mental confusion. This client may have difficulty complying with the postoperative treatment regimen.The client with hypertension, the client with sleep apnea, and the client with diabetes are all candidates for bariatric surgery despite having these complications.

How does the 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 The correct formula to accurately calculate a client's body mass index (BMI) is: BMI = weight (kg)/height (in meters)2.

The 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 and notifies the health care provider (HCP) b. Documents the findings and continues to monitor c. Slows the rate of flow of the IVFE infusion d. Switches to total parenteral nutrition (TPN)

a. Discontinues the IVFE infusion and notifies the health care provider (HCP) If a client receiving an IVFE nutritional supplement develops fever, increased triglycerides and clotting problems, the nurse must discontinue the IVFE and notify the HCP. For clients receiving fat emulsions, the nurse would monitor for manifestations of fat overload syndrome, especially in those who are critically ill. These manifestations include fever, increased triglycerides, clotting problems, and multisystem organ failure. The IVFE infusion must be discontinued, and the nurse must report any of these changes to the HCP immediately if this complication is suspected.Documenting the findings and continuing to monitor will have serious repercussions for this client. Slowing the rate of flow of the IVFE infusion will present a serious safety risk. Nurses do not request IV parenteral therapies or change them unless ordered by the HCP.

An obese client has been taking orlistat (Xenical) 60 mg orally three times a day for 4 weeks, but has only lost 10 pounds (4.5 kg). The health care provider doubles the dosage and recommends behavioral changes. What behavioral changes does the nurse include 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, c, d Self-monitoring techniques the nurse includes in the teaching plan are keeping a record of foods eaten (food diary), identifying emotional and situational factors that stimulate eating, and exercise patterns. Stimulus control involves controlling the external cues that promote overeating.Cognitive restructuring involves modifying negative beliefs by learning positive, not negative, coping self-statements. Healthy eating behaviors must be learned or modified by the client as an individual and not through copying or modeling others' behaviors.

The 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, c, d, e "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." Lifestyle changes the nurse emphasizes include consuming a diet that is moderate in salt and sugar and low in fats and cholesterol, and moderate physical activity for at least 30 minutes each day. These are smart strategies for a person who wants to lose weight. Eating a variety of foods, especially grain products, vegetables, and fruits, helps people achieve weight loss. These are foods that "burn" more calories as they are metabolized. Many foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home. When dining out, people can make smart choices, but they have to be educated and careful.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. Liquid dietary supplements cannot safely be substituted for solid food while attempting to lose weight.

The nurse is teaching a class of older adults in the community about engaging in "regular" exercise. What does the nurse advise them? a. "One to two hours of cardiovascular exercise every day is a good idea." b. "Walking 30 to 40 minutes provides the same benefit as long periods of exercise." c. "You will benefit most if you get into a group that shares your exercise goals."

b. "Walking 30 to 40 minutes provides the same benefit as long periods of exercise." The nurse advises the class of older adults to walk 30 to 40 minutes five days per week. 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 can provide the same type of benefit. Older adults can engage in this type of exercise which does not cost anything (unlike joining a program) and provides health benefits such as strengthening joints and improving cardiovascular health.One to two hours of cardiovascular exercise every day is not required to achieve benefits of exercise. Joining a gym is not necessary. In addition, many older adults have a fixed income and cannot afford memberships. A 30-minute walk can be accomplished with a group (such as "mall walking") or alone.

Which serum albumin level does the nurse expect to see in a healthy, ambulatory adult client? a. 2.3 g/dL (23 g/L) b. 3.7 g/dL (37 g/L) c. 5.1 g/dL (51 g/L) d. 5.8 g/dL (58 g/L)

b. 3.7 g/dL (37 g/L) The normal serum albumin level for men and women is 3.5 to 5.0 g/dL (35 to 50 g/L).The other options given are incorrect.

The nurse is teaching a group of adults in the community about the 2015-2020 Dietary Guidelines for Americans. What does the nurse emphasize as a dietary strategy suggested in these guidelines? a. Half of each meal should consist of dairy, fruits, and proteins. b. Adults should focus on variety and nutrient density and not calories. c. Older adults should consider lacto-ovarian diets for improved health. d. Adults should include a multivitamin with iron and vitamin B12 in their diet.

b. Adults should focus on variety and nutrient density and not calories. The nurse emphasizes the need to focus on "shifts" to include a variety of nutrient-dense foods rather than less nutritious foods. The focus involves the client making active choices. This strategy is included in the 2015-2020 Dietary Guidelines for Americans. Examples of other guidelines are listed in Table 60-1.The most recent guidelines in 2015-2020 do not recommend that half of the diet include proteins and dairy. Using the My Plate recommendations, half of the diet should be fruits and vegetables. Lacto-ovarian diets are not emphasized. A multivitamin with iron and B12 is not recommended if the diet is adequate.

An older adult with severe rheumatoid arthritis in the upper extremities is malnourished. What does the nurse suspect as the cause of 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 The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils.No evidence suggests that the client is experiencing a decrease in appetite or is financially unable to purchase adequate food. No evidence suggests that the client is immobile because of osteoarthritis in the extremities. Metabolic requirements would decrease, not increase, with less mobility.

An underweight 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. Assesses the client's skin for evidence of breakdown weekly

b. Makes certain the client is weighed daily at the same time To assess the effectiveness of supplements for this client, the nurse would perform daily weigh-ins. This will best show the effects of nutritional supplements since the primary client outcome is weight gain.Identifying everything that the client is taking in orally, monitoring vital signs, and assessing for any evidence of skin breakdown do not help determine the effects of nutritional supplements for the client.

An obese client is prescribed orlistat (Xenical). The client asks the nurse how the drug 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."

c. "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." The nurse explains to the client that Orlistat inhibits lipase and leads to partial hydrolysis of triglycerides. Because fats are only partially digested and absorbed, calorie intake is decreased.Orlistat does not decrease the amount of norepinephrine in the brain, increase the amount of serotonin in the brain, or alter the chemistry of the brain.

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 any changes 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 any changes in your menstrual cycle each month." The best response by the nurse is to ask the client who is concerned about her inability to conceive, is to ask her about changes in her menstrual cycle each month. Obesity has been known to produce changes in the menstrual cycle, thus causing difficulties in getting pregnant. Asking the client about her menstrual cycle directly addresses the client's concern and is designed to elicit helpful assessment information.Asking the client if she feels her obesity is keeping her from getting pregnant only asks the client to restate the obvious. It is also a closed question that requires only a "yes-or-no" response. Telling the client that adoption is an option is an intrusive response by the nurse and may alienate the client. It also does not address the client's concern about obesity. Asking what her health care provider told her is an evasive response from the nurse and does not address the client's concerns.

The nurse is performing a health assessment on an obese client who 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." The best way to assess a client's response to obesity and stress is to say, "Tell me what you do to relieve stress in your daily life." This open-ended type of question is best because it cannot be answered with a "yes" or "no."Asking the client about mental health problems will cause the client to feel uncomfortable with the assessment; problems in handling stress do not mean mental health or depression problems. More effective methods can be used to determine the client's alcohol and drug habits. Having the client tell you what makes him or her uncomfortable about obesity will only cause the client to restate the obvious. It does not determine the effect that stress has on the client.

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 The nurse tells the client to expect loose stools, abdominal cramps, and nausea. These are side effects unique to orlistat (Xenical).Dry mouth, constipation, and insomnia are not side effects of orlistat. Insomnia, dry mouth, blurred vision, palpitations, constipation, and restlessness are all side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate), 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 most effectively plan nutritional care for this client? a. Calculates his body mass index (BMI) b. Records a 24-hour diary of his physical activities c. Obtains a 24-hour recall (diary) of his food intake d. Measures his accurate height and weight measurements

c. Obtains a 24-hour recall (diary) of his food intake The most effective way to plan nutritional care for a client is to obtain a 24-hour recall of food intake. This will determine the client's food preferences and eating patterns so that they can be incorporated into the diet.Although calculating a BMI and measuring height and weight are important parts of a nutritional assessment, they do not address the issue of the client's food preferences. Keeping an activity diary will also not reveal any information related to the client's food preferences.

An older malnourished client who is taking digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel) develops a severe case of diarrhea. What does the nurse suspect is a possible cause? a. Digoxin (Lanoxin) b. Gastritis c. Potassium chloride (Kay Ciel) d. Ranitidine (Zantac)

c. Potassium chloride (Kay Ciel) The nurse suspects that potassium chloride may be the possible cause. In some cases, Potassium chloride (Kay Ciel) may cause diarrhea. This may be the result of liquid medications such as elixirs and suspensions that have a very high osmolality.Diarrhea is not a frequent side effect of digoxin or ranitidine (Zantac). Gastritis does not cause diarrhea, and the other signs and symptoms of gastritis are not mentioned in this scenario.

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. Observing for tachycardia, nausea, diarrhea, and abdominal cramping c. Providing six small feedings daily and offering fluids frequently

c. Providing six small feedings daily and offering fluids frequently The nursing intervention with the highest priority to prevent dehydration in a post-operative bariatric client is small daily feedings and adequate fluids. This will prevent the development of dehydration in this client.Ambulation will prevent pulmonary embolism and other circulatory problems. An abdominal binder will help support the abdomen and may prevent dehiscence of the wound. Observing for tachycardia, nausea, diarrhea, and abdominal cramping will prevent the development of postoperative dumping syndrome. All of these interventions are important, but preventing dehydration is the priority

A client who is receiving total enteral nutrition 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 dislodged. b. Severe hyperglycemia is present. c. Refeeding syndrome is occurring.

c. Refeeding syndrome is occurring. Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to clients who are starved, severely malnourished or metabolically stressed due to severe illness. Symptoms of refeeding syndrome include shallow respirations, weakness, acute confusion, seizures, and increased bleeding tendency.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. Abdominal distention is most frequently accompanied by nausea and vomiting. In refeeding syndrome, insulin secretion decreases in response to the physiologic changes in the body, so hyperglycemia is not present. When refeeding begins, insulin production resumes and the cells take up glucose and electrolytes from the bloodstream, thus depleting serum levels, resulting in hypoglycemia.

An 87-year-old resident from an extended care facility has not been eating for several days and 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 checks the gastric pH of the feeding tube and obtains a value of 6.0, which 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. The client may be taking the drug Zantac. The pH may be as high as 6.0 if the client takes certain medications, such as histamine2 blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]). This finding, given the circumstances, does not mean that the tube is displaced and in the client's lungs.The NG tube does not have to be removed at this time. The potassium effect would not cause the pH to become more alkaline. Expired pH paper will provide no data that are reliable, so it would not be possible to have a reading of "6.0."

The nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" (157.5 cm) about what the BMI number means, and about malnutrition. 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."

d. "My goal should be to get my BMI below 18.5." The client statement showing a need for further instruction is, "My goal should be to get my BMI below 18.5." The least risk for malnutrition is associated with scores between 18.5 and 25.Older adults need to have a BMI between 23 and 27. The client with a BMI greater than 24.9 does have increased health risks that a client with a lower number would not have. 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.

An RN receives the change-of-shift report about these four clients. Which client does the nurse assess first? a. A 30-year-old admitted 2 hours ago with malnutrition associated with malabsorption syndrome b. A 45-year-old who had gastric bypass surgery and is reporting severe incisional pain c. A 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL (16.7 mmol/L) d. A 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min

d. A 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min The nurse first assesses the client with dementia who has a respiratory rate of 38 breaths/min. This client needs immediate respiratory assessment and interventions. Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness.The client with malnutrition associated with malabsorption syndrome, the client with incisional pain from gastric bypass surgery, and the client receiving TPN with a BG of 300 mg/dL (16.7 mmol/L) all need assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority.

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 The most effective intervention to increase the client's protein intake is to provide protein modular supplements in the form of puddings. This would increase the client's protein intake in a format other than a liquid supplement.Administering the liquid supplement with routine medications will not be effective because the client has already refused to drink the supplements. Glucose polymer modular supplements will increase the client's calorie intake but not protein intake. A food and fluid diary will provide information about the client's typical intake pattern, but will not increase protein intake.

An obese client with a body mass index of 30 and hypertension has been taking prescription orlistat for 4 weeks and reports loose stools, abdominal cramps, and nausea. What does the nurse recommend for this client? a. Asking the provider to change the medication to phendimetrazine (Bontril). b. Changing to the lower dose, over-the-counter form of orlistat to reduce these effects. c. Increasing the daily activity level to improve overall metabolism. d. Reducing nutritional fat intake to less than 30% of the client's daily food intake.

d. Reducing nutritional fat intake to less than 30% of the client's daily food intake. The nurse recommends reducing nutritional fat intake to less than 30% of the client's daily food intake. Loose stools, abdominal cramps, and nausea are common side effects of orlistat and can be reduced by decreasing fat intake.Unless side effects persist or become more severe, it is not necessary to change the medication. Reducing the dose of orlistat does not affect these symptoms, since they are dependent on fat intake. Increasing the daily activity level helps with weight loss, but does not reduce side effects of Orlistat.

The 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. The nurse reports a urine output total of 15 mL for the past two hours. Normal urine output needs to be at least 30 mL per hour. Oliguria (scant urine output) may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure.Inaudible bowel sounds would typically require intervention, but on the day of surgery, bowel sounds will probably be absent normally for some time. The other findings, excoriated skin under the panniculus and subjective reports of pain, may require nursing interventions, but do not require an immediate report to the surgeon.

A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents injury to the client who is being re-positioned postoperatively? a. Administering pain medication b. Making sure not to move the client's nasogastric (NG) tube c. Monitoring skinfold 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 The most effective way to reposition a post-operative bariatric client and prevent injury is to use a special weight-related extra wide bed. This will allow adequate room for re-positioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury.Pain medication and monitoring skinfold areas will not prevent injury to the client that might occur during repositioning. Not moving the client's NG tube will prevent disruption of the suture line, but will not prevent repositioning injuries.