EAQ CH 46

A 70-year-old patient came to the clinic for a regular checkup. The patient lives alone. On assessment, the nurse finds that the patient has experienced a weight loss of 5 pounds and has a poor nutritional status. The nurse decides to assess the food preferences and dietary intake of this patient. Which questions should the nurse ask the patient?

"Do you follow any special diet due to your medical condition?" "How many meals do you have in a day?" "How do you prepare your food?"

Which statement made by an adult patient demonstrates understanding of the nurse's healthy nutrition teaching?

"I will make sure that I eat a balanced diet and exercise regularly."

The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked, because he does not have diabetes. What is the best response by the nurse?

"TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range."

The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention?

Gastric residual aspirate of 350 mL for the second consecutive time

The nurse is assisting an older adult with dysphagia to eat. What should the nurse avoid?

Giving large bites to stimulate the swallow reflex

The nurse is providing care to a patient who has reached the maximum administration rate for the prescribed enteral feedings. How often should the nurse weigh the patient based on the current data?

Three times per week

The nurse is caring for a patient with dysphagia. Of what complications of dysphagia should the nurse be aware? Select all that apply.

Weight loss Decreased nutritional status Dehydration Aspiration pneumonia

The U.S. Food and Drug Administration (FDA) created daily values for food labels. These daily values are based on percentages of a diet consisting of how many kilocalories per day?

2000

A patient is 5 feet, 10 inches tall, and has a weight of 70 kg. What would be the body mass index (BMI) of the patient? Do your calculations and record your answer using two decimal places. __________ kg

22.09

Following cardiac surgery, a patient is on a diet to reduce cholesterol. What is the recommended cholesterol intake in this diet? Record your answer using a whole number. __________ mg/day

300

Which medication prescription would the nurse expect to see in the medical record prior to intubating a patient with a nasointestinal (NI) tube?

Metoclopramide

Which substances comprise the referenced daily intakes (RDIs) that the U.S. Food and Drug Administration (FDA) has established? Select all that apply.

Minerals Vitamins Proteins

During which phase of the nursing process does the nurse consult other health care professionals to adopt the best nursing intervention for a patient diagnosed with nutritional disturbances?

Planning

Which nursing action is appropriate when advancing the rate of a continuous tube feeding?

Programing the infusion pump at 10 to 40 mL per hour for the initial feeding

What is the maximum hang time for enteral feeding in an open system? Record your answer using whole number. _____ hours

8

The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition?

A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery

The nurse is providing care to a patient who is prescribed intermittent enteral feedings. Prior to the scheduled feeding, the nurse notes a gastric residual volume (GRV) of 260 mL. Which nursing action is the priority?

Rechecking the GRV in 1 hour

Which term describes the suggested intake for individuals based on experimentally determined estimates of nutrient intakes?

Adequate intake

A 70-year-old patient is admitted to the hospital after having a stroke. The patient suffers from right-sided hemiplegia. The nurse finds that the patient has dysphagia. What precautions should the nurse take when feeding the patient? Select all that apply.

Allow the patient time to empty the mouth before each spoonful. Have the patient flex the head slightly to a chin-down position. Position the patient in an upright, seated position. Schedule a 30-minute rest period before eating

To digest starch, which enzyme does the pancreas secrete?

Amylase

What test should be performed to confirm the correct placement of a nasogastric (NG) feeding tube before the start of feedings?

An x-ray study

What are the indications for enteral nutrition? Select all that apply.

Anorexia nervosa Prolonged intubation Difficulty chewing

A patient on enteral feeding complains of diarrhea. What could be the possible causes of this health condition? Select all that apply.

Antibiotic therapy Bacterial contamination Hyperosmolar formula

Which equipment should the nurse have available when testing a patient's blood glucose level? Select all that apply.

Antiseptic swab Paper towel Lancet

The nurse is caring for a patient who is scheduled for an x-ray for an injured right leg. Which intervention may help reduce the patient's pain?

Applying ice near the site of the pain

A 70-year-old patient is admitted to the hospital post stroke. The patient suffers from right-sided hemiplegia and dysphagia. Which complication of dysphagia might the nurse observe in the patient?

Aspiration pneumonia

The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the steps of the procedure in the correct sequence.

Blood glucose should be monitored every 6 hours for a patient receiving parenteral nutrition (PN). The procedure begins with assessment of the patient's skin to identify an appropriate puncture site. Explain the procedure to the patient and/or family and then perform hand hygiene. Position the patient comfortably, remove the reagent strip from the container, and check the code on the test strip vial. Insert the strip into the glucose meter and place the loaded glucose meter on a clean, dry surface with the test pad facing up. Apply clean gloves, select your puncture site, and clean the site with antiseptic solution. Use the lancet to pierce the skin and wipe away the first droplet of blood with a cotton ball. Lightly squeeze the puncture site and wick the blood drop onto the test strip. The blood glucose result will appear on the screen. The final step is documentation of the results in the patient's medical record. Test-Taking Tip: When one choice is to document results in the medical record, it is usually the last step. First, determining which step is last and which step is first makes the prioritizing questions easier.

The nurse has explained the nutritional requirements of a newborn to a new parent. Which statement by the parent indicates a need for further explanation?

Cow's whole milk is a suitable alternative for breast milk.

The nurse is caring for a patient who is on tube feeding. What signs and symptoms suggest intolerance to feedings? Select all that apply.

Cramping Vomiting Nausea High gastric residual

Which findings would necessitate further intervention by the nurse when caring for a patient with a gastrostomy tube inserted through the abdominal wall? Select all that apply.

Redness and irritation at the insertion site An excessively snug external disk Watery stool over the last day

Until radiographic confirmation of placement of an intestinal tube is completed, in which position should the nurse place the patient after intubation?

Side-lying

Which nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding?

Discarding gastric contents

Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions?

Elevating the head of the bed to a 90-degree angle

The nurse is helping a patient with vision impairment to feed himself. What nursing actions would help the patient maintain independence during feeding? Select all that apply.

Encourage the use of large-handled adaptive utensils. Ensure the other care providers set the meal tray and plate in the same manner. Identify the food location on a meal plate as if it were a clock. Tell the patient where the beverages are located in relation to the plate.

A patient needs enteral feedings via a nasoenteric tube. Which action does not take place during the assessment phase for this patient?

Explaining the procedure to the patient

Which nursing action is appropriate when planning to intubate a patient with a prescribed feeding tube?

Explaining the sensations that are expected

Which nursing actions are appropriate when preparing the syringe for an intermittent nasoenteric feeding to a patient? Select all that apply.

Fill the syringe with the measured amount of formula and elevate Attach the barrel of the syringe to the end of the tube Remove the plunger from the syringe

A 70-year-old patient is admitted to the hospital post stroke with right-sided hemiplegia. The nurse suspects the patient has dysphagia. What should the nurse note to confirm dysphagia while assessing the patient? Select all that apply.

Slow, weak, imprecise, or uncoordinated speech Abnormal movements of the mouth, tongue, and lips A change in voice tone after swallowing Coughing during eating

A nurse must administer enteral feeding via nasoenteric tube to a patient. In what order should the nurse perform the procedure?

First, the nurse should obtain the baseline weight and laboratory values to assess the nutritional status of the patient. Then, the nurse should identify the patient using two identifiers according to the agency policy. After this, the nurse should attach the syringe and aspirate 5 mL of gastric contents to verify tube placement. Lastly, the nurse should monitor the intake and output every 8 hours and calculate the daily totals every 24 hours during the evaluation phase. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration

In renal failure, protein intake should be approximately 1 g to 1.4 g per kilogram of body weight. What is the best source of this protein?

Fish

Following cardiac surgery, a patient is kept on nothing by mouth for 3 days. What should be the sequence of diet progression in this patient?

Following surgery, or when the patient is kept on nothing by mouth for a prolonged period, the patient has to be put on a gradual progression of dietary intake or a therapeutic diet. The patient is given clear liquids followed by full liquids and then pureed liquids. If the patient tolerates these well, a mechanical soft diet can be started. If the patient is comfortable, a low-residue diet can be added followed by a high-fiber diet.

A 70-year-old hypertensive patient came to the clinic for a regular checkup. On assessment, the nurse finds that the patient has experienced a weight loss of 5 pounds and has a poor nutritional status. Which physical signs are indicative of poor nutritional status? Select all that apply.

Spoon-shaped and brittle nails Flaccid, wasted muscles Dry scaly lips

In what order does the nurse implement the following steps while administering enteral feedings via nasoenteric tube?

For administering enteral feedings via nasoenteric tube, the nurse should first place the patient in high-Fowler's position or elevate the head of the bed at least 30 degrees. The nurse should then verify the tube placement by attaching the syringe and aspirating 5 mL of gastric contents. Next, the nurse should flush the tubing with 30 mL of water. After this, feeding should be initiated by removing the plunger from the syringe and attaching the barrel of syringe to end of tube. The nurse should then advance the rate of tube feeding as ordered by health care provider. Lastly, the nurse should rinse the bag and tubing with warm water whenever feedings are interrupted. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration

A postoperative patient is advised to take clear fluids. What types of fluids should the nurse provide to the patient? Select all that apply.

Carbonated beverages Coffee Tea

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.

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 the institution's protocol for use of a thrombolytic agent (e.g., urokinase).

Which data should nurse document in the patient's medical record after the intubation of an enteral tube? Select all that apply.

Confirmation of tube placement by x-ray film pH value of gastric aspirate Size of the tube Type of tube

The nurse is caring for a patient diagnosed with hemorrhoids. While taking the patient's clinical history and vitals, the nurse finds that the patient has chronic constipation. What should the nurse teach the patient about the diet? Select all that apply.

Fruits and vegetables relieve constipation. Fluid and fiber intake should be increased. Food rich in fiber relieves constipation.

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?

Helicobacter pylori

Which assessments should the nurse perform prior to inserting a nasoenteric tube for enteral feedings? Select all that apply.

Hydration status weight height

A patient is on parenteral nutrition. For which complications should the nurse look? Select all that apply.

Hypercapnia Electrolyte imbalance Hyperglycemia

Which complication may occur if the nurse were to add food coloring to the formula for a patient who is prescribed enteral feeding?

Hypotension

Which priority nursing action complies with the Joint Commission standards and promotes patient safety when administering an enteral feeding by a nasoenteric tube?

Identifying the patient using two identifiers

Which nursing action is appropriate when advancing the rate of an intermittent tube feeding?

Infusing a bolus of formula over 20 to 30 minutes

Which skill should the nurse delegate to a nursing assistive person (NAP) when providing care to a patient who is receiving enteral feedings?

Infusing the patient's feeding per prescriber order

Which is the priority nursing action when evaluating the patient after the insertion of an enteral feeding tube?

Inspecting the patient's naris for irritation

What is the function of the hormone cholecystokinin?

It inhibits the secretion of gastrin.

The nurse is checking feeding tube placement. Place the steps in the proper sequence.

It is important to check feeding tube placement at least every 4 hours for continuous enteral feedings and before intermittent enteral feedings. Checking the feeding tube placement is an important intervention used to decrease the risk of aspiration in patients receiving enteral feedings. The procedure follows a 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. Test-Taking Tip: Often in the sequencing type question, the step just before beginning the procedure is to perform hand hygiene and put on clean gloves. If this is a choice, examine whether any other steps (such as closing the door or pulling the curtain closed) need to be done before it. Otherwise, you can consider the hand hygiene step as the first step.

What is the advantage of enteral feeding over parenteral feeding?

It maintains intestinal function and integrity.

The nurse is caring for a patient who is on enteral feeding. What are the advantages of enteral feeding? Select all that apply.

It maintains intestinal structure and function. It decreases hospital mortality. It reduces sepsis

Which are possible causes for constipation in a patient who is prescribed enteral tube feedings? Select all that apply.

Lack of fiber in the diet Inactivity

Which food items contain gluten and should be avoided in patients with celiac disease? Select all that apply.

Oats Barley Rye Wheat

Which nursing action is appropriate when observing a patient for dysphagia during an aspiration risk assessment?

Observing the patient eat various consistencies of food

A postoperative patient refuses to eat and complains of a loss of appetite. What intervention should the nurse perform to improve the patient's appetite?

Offer smaller and more frequent meals

Following an assessment of a patient, the nurse finds that the patient is malnourished. What were the patient's assessment findings? Select all that apply.

Pale conjunctiva Hair loss Poor muscle tone

Which information should the nurse include on the label of an enteral feeding to promote patient safety? Select all that apply.

Patient's room number Rate of feeding Patient's name Date and time

Which enzyme do the chief cells of the stomach secrete?

Pepsinogen

Which is the first nursing action when monitoring a patient's blood glucose level?

Performing hand hygiene

The nurse is feeding a patient with dysphagia. Which action performed by the nurse during feeding may lead to aspiration?

The nurse extends the patient's head to a chin-up position.

An adult patient has a body mass index (BMI) of 20 kg/m2. What should the nurse interpret from this?

The patient has a healthy weight.

The nurse weighs a patient with renal failure and finds the body weight to be 112 pounds. The patient's weight on the previous day was 110 pounds. What should the nurse interpret from the finding?

The patient has retained a liter of fluids.

The nurse is assessing the patient prior to drawing a prescribed blood glucose level. In which order should the nurse perform the following actions?

To assess a patient who is prescribed blood glucose monitoring, the nurse should first assess the patient's understanding of the procedure. Second, the nurse should assess the skin at the site to be used for the procedure. Next, the nurse should determine if there are any risk for performing a skin puncture, such as a low platelet count which could increase the patient's risk for bleeding. Following that, the nurse should review the health care provider's order for time of frequency of measurement. Finally, the fifth step is to determine if certain conditions must be met prior to implementing the prescribed procedure.

The nurse is consulting with a patient about meal planning on an allocated budget. What advice should the nurse provide to help ensure good nutrition on a budget? Select all that apply.

Use evaporated milk for cooking. Avoid grocery shopping when hungry. Plan menus a week in advance.

What is the most important nursing intervention that the nurse should provide to a patient who is diagnosed with ineffective coping related to improper nutrition?

Using an active listening approach when talking with the patient

Which nursing action promotes safety of a patient who is prescribed continuous enteral feeding?

Using an infusion pump

Which action is the nurse most unlikely to perform during blood glucose monitoring of a patient?

Using the first drop of blood obtained after puncturing

The nurse has inserted a nasogastric tube into a patient. However, when the first feeding is administered, the patient has pulmonary aspiration. Which action would have prevented this complication?

Verifying the placement of the tube through x-ray

The nurse is conducting a health awareness program on food safety for a group of patients and their relatives. What information should the nurse include in the teachings? Select all that apply.

Wash cutting boards with hot, soapy water. Do not save leftovers for more than 2 days in the refrigerator. Unpasteurized milk is not safe for children or adults.

The nurse is preparing to administer a nasoenteric feeding to a patient. In which order should the nurse perform the following actions?

When administering a nasoenteric feeding to a patient the correct sequence of events begins with shaking the formula. Next, the nurse should cleanse the top of the formula can with alcohol prior to opening. The third step is to fill the container with fluid, and the fourth step is to open the roller clamp on the tubing and fill to remove air. The final step is to hang the formula on an intravenous pole. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

The nurse aspirates gastric contents to assess pH in a patient who is prescribed intermittent enteral feedings. In which order should the nurse perform the following actions?

When assessing pH of gastric aspirate, the nurse first observes the appearance of the aspirate. Next, the nurse mixes the aspirate in the syringe. The third step is to expel a few drops of aspirate into a clean medicine cup. Next the nurse dips the pH strip into the aspirate fluid. Finally, the nurse compares the color on the strip to the color chart provided by the manufacturer. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

The nurse is preparing the syringe for an intermittent nasoenteric feeding to a patient. In which order should the nurse perform the following actions?

When preparing the syringe for an intermittent nasoenteric feeding to a patient, the nurse should first pinch the proximal end of the tubing. Second, the nurse should remove the plunger from the syringe. Next, the nurse should attach the barrel of the syringe to the end of the tube, and then fill the syringe with the measured amount of formula and elevate. Finally, the nurse should allow the formula to empty gradually by gravity.

A patient underwent a partial gastrectomy with the removal of parietal cells of the stomach. For which vitamin deficiency should the nurse look in the patient?

b12

When the nurse monitors blood glucose, during which phase of the nursing process does the nurse explain the procedure and purpose to the patient?

planning

Which equipment should the nurse have available when assessing the pH of gastric aspirate?

test paper