Chapter 44 Nutrition
1 Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching? 1I need to stop eating red meat. 2I will increase the servings of fruit juice to four a day. 3I will make sure that I eat a balanced diet and exercise regularly. 4I will not eat so many dark green vegetables and eat more yellow vegetables.
1. Answer: 3. Obesity is an epidemic in the United States. Proposed contributing factors are sedentary lifestyle and poor meal choices. Healthy eating and participation in exercise or other activities of healthy living promote good health.
1 As part of your next visit to the senior citizens' center where Mrs. Cooper lives, you plan to present a program to the residents to help decrease their risk of cardiovascular disease. Using your knowledge of medical nutrition therapy (MNT), summarize five points that you will include in the program for the residents.
1. The purpose of MNT is to use nutritional therapies to treat illness, correct nutritional deficiencies related to the cardiovascular disease, and eliminate foods that exacerbate cardiovascular disease symptoms. Five points related to MNT to include in the program to reduce cardiovascular disease include: • The diet should include carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk. • Limit saturated fat to less than 7% of the total calories and cholesterol to less than 200 mg per day. • Include a variety of foods that contain fiber. • Sugar alcohols and nonnutritive sweeteners are acceptable as long as the daily intake levels are followed. • Sucrose can be used as a substitute for carbohydrates but avoid it as excess energy intake.
10 The nurse is checking feeding tube placement. Place the steps in the proper sequence. 1Draw 5 to 10 mL gastric aspirate into syringe. 2Flush tube with 30 mL air. 3Mix aspirate in syringe and place in medicine cup. 4Observe color of gastric aspirate. 5Perform hand hygiene and put on clean gloves. 6Dip pH strip into gastric aspirate. 7Compare strip with color chart from manufacturer.
10. Answer: 5, 2, 1, 4, 3, 6, 7. It is important to check feeding tube placement at least every 4 hours for continuous enteral feedings and before intermittent enteral feedings. Checking feeding tube placement is an important intervention used to decrease the risk of aspiration in patients receiving enteral feedings. The procedure follows a set series of steps, starting with performing hand hygiene and putting on gloves to decrease the transmission of microorganisms. The final step is comparing the strip with the color chart from the manufacturer to assess the color and pH of the aspirate.
11 Which statement made by a patient of a 2-month-old infant requires further education? 1I'll continue to use formula for the baby until he is a least a year old. 2I'll make sure that I purchase iron-fortified formula. 3I'll start feeding the baby cereal at 4 months. 4I'm going to alternate formula with whole milk starting next month.
11. Answer: 4. Infants should not have regular cow's milk during the first year of life. It causes gastrointestinal bleeding, is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The development of fine-motor skills of the hand and fingers parallels the infant's interest in food and self-feeding. Iron-fortified cereals are typically the first semisolid food to be introduced. For infants 4 to 11 months, cereals are the most important nonmilk source of protein.
12 The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) 1Avoid grapefruit and grapefruit juice, which impair drug absorption. 2Increase the amount of carbohydrates for energy. 3Take a multivitamin that includes vitamin D for bone health. 4Cheese and eggs are good sources of protein. 5Limit fluids to decrease the risk of edema.
12. Answer: 1, 3, 4. Caution older adults to avoid grapefruit and grapefruit juice because these impair absorption of many drugs. Thirst sensation diminishes, leading to inadequate fluid intake or dehydration; thus older adults should be encouraged to ingest adequate fluids. Some older adults avoid meats because of cost or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Milk continues to be an important food for older women and men who need adequate calcium to protect against osteoporosis (a decrease of bone mass density). Screening and treatment are necessary for both older men and women. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bone fractures.
14 The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? 1TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. 2The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. 3Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. 4Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention.
14. Answer: 1. The TPN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Administration of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. Blood glucose levels should be monitored every 6 hours to assess for hyperglycemia. Maintaining blood glucose within acceptable limits helps prevent complications from the TPN.
15 The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the steps of the procedure in the correct sequence. 1Clean puncture site with antiseptic solution. 2Identify patient using two identifiers. 3Check code on test strip vial. 4Wick blood drop into test strip. 5Gently squeeze fingertip until drop of blood appears. 6Assess area of skin to be used as puncture site. 7Read results and document in medical record.
15. Answer: 6, 2, 3, 1, 5, 4, 7. Blood glucose should be monitored every 6 hours for a patient receiving TPN. The skill begins with assessment of the patient's skin to identify an appropriate puncture site. The final step is documentation of the results in the patient's medical record.
2 The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? 1Fat 2Protein 3Vitamin 4Carbohydrate
2. Answer: 2. Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue in growth, maintenance, and repair. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein.
2 Six months later, Mrs. Cooper is admitted to the hospital for a viral infection. She had a recent weight loss of 6 pounds in the week before admission and lost an additional 4 pounds during the week of hospitalization. Her appetite is poor; she has frequent nausea and vomiting. Her abdomen is soft and nontender, and bowel sounds are present. The health care provider orders enteral feedings to be started. aWhat type of tube should be selected? bHow is the tube placement verified? cDescribe the type of feeding and initiation of feedings. dWhich complications of tube feeding should be assessed?
2. a. Small-bore nasointestinal tube is best for feeding. This reduces the risk of aspiration. b. Because the tube in is the intestine, initial tube placement is verified by x-ray film. c. Begin tube feedings with a polymeric (10 to 2 kcal/mL) whole-nutrient formula. Mrs. Cooper does not have any contraindications such as dysfunctional gastrointestinal absorption, liver failure, pulmonary disease, or human immunodeficiency virus (HIV) infection to using this type of formula. d. Complications that Mrs. Cooper needs to be assessed for include aspiration, diarrhea, constipation, abdominal cramping, nausea, vomiting, delayed gastric emptying, fluid overload, hyperosmolar dehydration, and serum electrolyte imbalances.
3 Two years after her husband died, Mrs. Cooper suffered a stroke and developed dysphagia. Develop a plan of care for assisting Mrs. Cooper with meals to reduce the risk of aspiration. Answers to Clinical Applica
3. A plan of care for Mrs. Cooper to reduce the risk of aspiration caused by her dysphagia includes the following points: • Have her rest 30 minutes before each meal. • Sit her upright in a chair to eat. • Place small bites of food on the strong side of her mouth. • Encourage her to chew thoroughly and swallow. • Wait until her mouth is empty before placing the next bite. • Thicken food and liquids to viscosity that is appropriate for her and makes swallowing easier. • Have Mrs. Cooper sit up for at least 30 minutes after eating.
3 The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select all that apply.) 1Sit the patient upright in a chair. 2Give liquids at the end of the meal. 3Place food in the strong side of the mouth. 4Provide thin foods to make it easier to swallow. 5Feed the patient slowly, allowing time to chew and swallow. 6Encourage patient to lie down to rest for 30 minutes after eating.
3. Answer: 1, 3, 5. Patients with dysphagia are at risk for aspiration and need more assistance with feeding and swallowing. Feed the patient with dysphagia slowly, providing smaller-size bites, and allow the patient to chew thoroughly and swallow the bite before taking another. Position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. If the patient has unilateral weakness, teach him or her and caregiver to place food in the stronger side of the mouth. Additional interventions include providing a 30-minute rest period before eating. Have the patient slightly flex the head to a chin-down position to help prevent aspiration. Determine the viscosity of foods that the patient tolerates best through the use of trials of different consistencies of foods and fluids. Thicker fluids are generally easier to swallow. More frequent chewing and swallowing assessments throughout the meal are necessary. Allow the patient time to empty the mouth after each spoonful, matching the speed of feeding to the patient's readiness. If the patient begins to cough or choke, remove the food immediately.
4 The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first? 1Raise head of bed to 90 degrees 2Turn patient to left lateral decubitus position 3Notify health care provider immediately 4Have patient perform the Valsalva maneuver
4. Answer: 2. An air embolus possibly occurs during insertion of the catheter or when changing the tubing or cap. Have the patient assume a left lateral decubitus position first. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down"). The increased venous pressure created by the maneuver prevents air from entering the bloodstream during catheter insertion. Maintaining integrity of the closed intravenous system also helps prevent air embolus.
5 Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? 1Placing an order for x-ray film examination to check position 2Confirming the distal mark on the feeding tube after taping 3Testing the pH of the gastric contents and observing the color 4Auscultating over the gastric area as air is injected into the tube
5. Answer: 1. At present the most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination. The measurement of the pH of gastric secretions withdrawn from the feeding tube helps to determine the location of the tube. Auscultation has repeatedly been shown to be ineffective in detecting tubes accidentally placed in the lung. Further, it is not effective in distinguishing between gastric and intestinal placement for feeding tubes.
6 The catheter of the patient receiving parenteral nutrition (PN) becomes occluded. Place the steps for caring for the occluded catheter in the order in which the nurse would perform them. 1Attempt to aspirate a clot. 2Temporarily stop the infusion. 3Flush the line with saline or heparin. 4Use a thrombolytic agent if ordered or per protocol.
6. Answer: 2, 3, 1, 4. Catheter occlusion is present when there is sluggish or no flow through the catheter. Temporarily stop the infusion and flush with saline or heparin per protocol or orders. If this is unsuccessful, attempt to aspirate a clot. If still unsuccessful, follow institution protocol for use of thrombolytic agent (e.g., urokinase).
7 Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD? 1Micrococcus 2Staphylococcus 3Corynebacterium 4Helicobacter pylori
7. Answer: 4. Marshall and Warren first identified Helicobacter pylori in 1984. It is a bacteria that causes up to 85% of peptic ulcers and is confirmed by laboratory tests. It is treated with antibiotics that control the bacterial infection.
8 The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention? 1Gastric pH of 4.0 during placement check 2Weight gain of 1 pound over the course of a week 3Active bowel sounds in the four abdominal quadrants 4Gastric residual aspirate of 350 mL for the second consecutive time
8. Answer: 4. Delayed gastric emptying is a concern if 250 mL or more remains in the patient's stomach on each of two consecutive assessments. The North American Summit on Aspiration in the Critically Ill Patient made the following recommendations regarding gastric residual volumes (GRVs): (1) stop feedings immediately if aspiration occurs; (2) withhold feedings and reassess patient tolerance to feedings if GRV is over 500 mL for two successive measurements; and (3) routinely evaluate the patient for aspiration and use nursing measures to reduce the risk of aspiration if GRV is between 250 and 500 mL.
9 The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? 1A 55-year-old obese man recently diagnosed with diabetes mellitus 2A recently widowed 76-year-old woman recovering from a mild stroke 3A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery 4A 46-year-old man recovering at home following coronary artery bypass surgery
9. Answer: 2. Older adults who are homebound and have a chronic illness have additional nutritional risks. Frequently this group lives alone with few or no social or financial resources to assist in obtaining or preparing nutritionally sound meals. This contributes to a risk for food insecurity caused by low income and poverty. In addition, the mild stroke might cause dysphagia.
13 The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: 1Fastens the tube to the gown with tape. 2Places the patient supine while giving a bath. 3Performs oral care for the patient. 4Elevates the head of the bed 45 degrees.
13. Answer: 2. Patients receiving enteral feedings should have the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated. Laying the patient supine increases the risk of aspiration of the feeding and should be avoided. This needs to be addressed to maintain patient safety.
