Ch 33: Nutrition
The nurse is teaching an older adult client about different types of proteins that can be eaten. Which foods will the nurse identify as containing dietary protein? Select all that apply.
beans nuts poultry fish Explanation:Dietary proteins are obtained from animal and plant food sources, which include milk, meat, fish, poultry, eggs, soy, legumes (peas, beans, and peanuts), nuts, and components of grains. Butter is a fat and not a source of protein.
The nurse is flushing a client's feeding tube with 50 mL of water after giving medications through it. When the client asks, "Why are you doing that?" what is the appropriate nursing response?
"Water helps keep the feeding tube free from obstruction." Explanation:The nurse will respond by teaching the client that this amount of water helps to keep the feeding tube patent. It is not meant to dissolve medication, nor to hydrate the client. Observing that the client seems concerned about a procedure does not answer the client's actual question.
The nurse is caring for a client who had a percutaneous endoscopic gastrostomy (PEG) tube inserted earlier in the day. Which interventions should you plan to perform? Select all that apply.
Administer prescribed analgesics, as needed. Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. Measure the length of exposed tube and compare it with the length documented after insertion. Avoid placing tension on the feeding tube. Explanation:A dressing should be used between the skin and bumper if drainage is present. Barrier gels are not used for this purpose.
A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply.
Adolescents Pregnant or lactating women Strict vegetarians Explanation: Vitamin deficiencies are inherent with a few populations. Adolescents often eat fast food or skip breakfast and are prone to having vitamin deficiencies. Pregnant or lactating women have higher nutritional demands and may not consume enough vitamins to meet the demand. The vegan or total vegetarian diet includes only foods from plants: fruits, vegetables, legumes (dried beans and peas), grains, seeds and nuts and they lack protein vitamins. Middle aged adults and non-smokers are not at risk.
At what period of life do nutrient needs stabilize?
Adulthood Explanation:Nutrient needs change across the life span in relation to growth, development, activity, and age. Periods of intense growth and development (such as during infancy, adolescence, pregnancy and lactation) increase nutrient needs. Nutrient needs stabilize during adulthood.
The nurse is preparing to insert a nasogastric tube into a client who is very anxious. Which nursing intervention is appropriate?
Agree upon a hand signal for when the client needs a pause. Explanation:It is important for the nurse to provide the anxious client with a means of control, such as a hand signal that can be used when the client needs a pause during insertion. Inserting the tube quickly is inappropriate, as this may frighten the client and damage mucosa. The nurse should never provide false reassurance, nor double the dose of prescribed medications.
An older adult client who has a BMI of 28.1 and gastroesophageal reflux disease (GERD) reports heartburn frequently. The nurse plans to teach the client how to manage and prevent heartburn. What information will the nurse include in the teaching for this client? Select all that apply.
Do not use products that contain nicotine, such as tobacco and vaping devices. Maintain a diet that is low in fat. Plan a nutritious diet that will allow you to lose weight. Explanation: When teaching a client who has GERD, the nurse will include the following information: no smoking, a diet low in fat, and lose weight. Nicotine in tobacco and vaping products lower esophageal sphincter pressure, allowing reflux of stomach contents into the esophagus. Fat in the diet delays emptying of the stomach and increases the likelihood of reflux. Being overweight (a BMI greater than 25) increases intra-abdominal pressure, pushing gastric contents into the esophagus. The client is instructed to raise the head of the bed 30 to 40 degrees. This means placing the legs of the head of the bed on blocks. Using two pillows causes a bend in the neck. Pillows do not raise the level of the esophagus. The client is also instructed to avoid eating before bedtime. Again, eating before bedtime allows for reflux. Alcohol relaxes the lower esophageal sphincter pressure and increases the production of gastric acid. Both of these physiologic actions allow for reflux
An older adult client who has a BMI of 28.1 and gastroesophageal reflux disease (GERD) reports heartburn frequently. The nurse plans to teach the client how to manage and prevent heartburn. What information will the nurse include in the teaching for this client? Select all that apply.
Do not use products that contain nicotine, such as tobacco and vaping devices. Maintain a diet that is low in fat. Plan a nutritious diet that will allow you to lose weight. Explanation:When teaching a client who has GERD, the nurse will include the following information: no smoking, a diet low in fat, and lose weight. Nicotine in tobacco and vaping products lower esophageal sphincter pressure, allowing reflux of stomach contents into the esophagus. Fat in the diet delays emptying of the stomach and increases the likelihood of reflux. Being overweight (a BMI greater than 25) increases intra-abdominal pressure, pushing gastric contents into the esophagus. The client is instructed to raise the head of the bed 30 to 40 degrees. This means placing the legs of the head of the bed on blocks. Using two pillows causes a bend in the neck. Pillows do not raise the level of the esophagus. The client is also instructed to avoid eating before bedtime. Again, eating before bedtime allows for reflux. Alcohol relaxes the lower esophageal sphincter pressure and increases the production of gastric acid. Both of these physiologic actions allow for reflux.
What independent nursing intervention can be implemented to stimulate appetite?
Encourage or provide oral care. Explanation:There are many methods of stimulating appetite in a client to prevent malnutrition. One independent nursing intervention that is useful is to encourage or provide oral care. Administering medications and recommending dietary supplements are useful but are not independent nursing actions. The health care provider would need to prescribe the medications. Assessing manifestations of malnutrition occurs after malnutrition is recognized.
A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake?
Encourage the client to eat in the dining room. Explanation:Encouraging the client to eat in the dining room will allow for socialization during meal time. This will have a positive effect on the amount of food consumed and provide enjoyment. Feeding the client in bed encourages isolation from other residents. Allowing the client to eat whenever they want does not support socialization. Discouraging the family is not recommended, as the family can provide support and be assistive to the client and their food needs.
A nurse has received a physician's order to insert a nasogastric tube in an adult client. What is the correct order for insertion of a nasogastric tube?
Measure the insertion distance. Insert the nasogastric tube to the pharynx. Have the client tuck his chin to the chest. Have the client take small sips of water. Insert the tube to the indicated mark. Aspirate a small amount of stomach contents and check pH. Explanation:The nurse should follow this order for the insertion of a nasogastric tube: Measure the insertion distance. Insert the nasogastric tube to the pharynx. Have the client tuck his chin to the chest. Have the client take small sips of water. Insert the tube to the indicated mark. Aspirate a small amount of stomach contents and check pH.
A postmenopausal client wishes to increase the amount of vitamin D that she consumes to help keep her bones strong. Which food will the nurse recommend?
Milk Explanation: Milk contains vitamin D, which helps with the absorption of calcium and phosphorous. The other choices do not.
The nurse is caring for a client who is pregnant. Which nutrition education will the nurse provide?
More servings of milk daily will be required. Explanation: Children, adolescents, pregnant women, and breastfeeding mothers require more servings per day of certain food groups, particularly the milk group. They do not need to be told to eliminate red meat or poultry or decrease intake of carbohydrates. The client should control weight gain to a set loss as detailed by the health care provider according to present weight.
The nurse is caring for a client who is pregnant. Which nutrition education will the nurse provide?
More servings of milk daily will be required. Explanation:Children, adolescents, pregnant women, and breastfeeding mothers require more servings per day of certain food groups, particularly the milk group. They do not need to be told to eliminate red meat or poultry or decrease intake of carbohydrates. The client should control weight gain to a set loss as detailed by the health care provider according to present weight.
Which laboratory test is the best indicator of a client in need of TPN?
Serum albumin Explanation:Assessment of serum albumin level is the best indicator of a client in need of total parenteral nutrition (TPN). Clients whose levels are 2.5 g/dL (25 g/L) or less are at severe risk for malnutrition. Creatinine is used to assess kidney function. Hemoglobin and hematocrit assess the red blood cells of a client.
A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition?
Serum albumin Explanation:Serum albumin levels can help measure protein levels in the body and are good indicators for nutrition status. Hemoglobin levels maintain red blood cells that carry oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs. Creatinine is a laboratory value that assesses kidney function. Oxygen saturation is the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood. It is best used to determine how well a client is oxygenating.
A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption?
Serum albumin 2.8 g/dL (28 g/L) Explanation:Normal serum albumin is 3.3 to 5 g/dL (33 to 50 g/L). Decreased albumin indicates malnutrition or malabsorption. Decreased Hgb indicates anemia. Increased creatinine indicates dehydration. Increased Hct indicates dehydration.
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which should the nurse educate the client about regarding TPN therapy? Select all that apply.
TPN has three primary components: proteins, carbohydrates, and fats. TPN has a high glucose concentration. TPN requires a PICC line or central venous access. Explanation: Total parenteral nutrition (TPN) has three primary components: proteins, carbohydrates, and fats; it also has a high glucose concentration. TPN does require a PICC line or central venous access. TPN is a hypertonic solution. Lipids or fats are added to add caloric value to meet energy requirements.
The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?
Teenager who is in the second trimester of pregnancy Explanation: Children, adolescents, pregnant women, and breast-feeding mothers require more servings per day of certain food groups, particularly the milk group. Therefore, the teen (adolescent) who is pregnant will require more milk servings. The other clients do not require more servings of milk.
The nurse is helping a client who eats a normal diet of 2000 calories daily to read a nutritional label on a box of cereal. Which nutrient does the nurse identify as appropriate for this client?
cholesterol less than 300 mg Explanation: Daily values are calculated in percentages based on standards set for total fat, saturated fat, cholesterol, sodium, carbohydrate, and fiber in a 2000-cal diet. Total fat should be less than 65 g; saturated fat should be less than 20 g; cholesterol should be less than 300 mg; and sodium should be less than 2400 mg.
A nurse is caring for a client who is reporting nausea. Which is a sign of nausea?
dizziness and perspiration Explanation: Nausea usually precedes vomiting. It is associated with dizziness and perspiration. Impaired swallowing is associated with clients who have dysphagia and not typically nausea. Slow pulse rate is not a symptom of nausea. Emotional distress may or may not be related to the client's condition.
The nurse is providing discharge teaching for a client who will continue to administer tube feedings at home. The client states, "I don't think I can do this." What is the appropriate nursing response?
"Perhaps we can contact a home health nurse to assist." Explanation:A home health nurse can be of assistance if a client is afraid or unable to self-administer tube feedings. Reassuring the client, inquiring who will feed the client, and why the client is afraid do not effectively address the client's need.
A female client tells the nurse, "I try to consume 2000 calories daily by eating a variety of proteins, carbohydrates, and fats." What is the appropriate nursing response?
"That is a healthy amount of daily caloric intake." Explanation:Healthy adult women on average require 1800 to 2400 cal/day, with a mix of proteins, carbohydrates, and fats. The nurse should affirm the client's dietary choices. Other answers are incorrect and do not counsel the client appropriately.
A nurse is conducting a health history interview for an older adult. Which question or statement should the nurse prioritize for nutritional assessment?
"Which prescribed and over-the-counter medicines do you take?" Explanation:When collecting dietary data for an older adult, it is important to gather information about prescribed and over-the-counter medications to assess for food-drug interactions and adverse effects of medications.
A client is receiving a continuous tube feeding using a commercially prepared formula at home. The nurse would instruct the client's caregiver to use the formula within which time frame once the container is opened?
24 hours Explanation:After opening a commercially prepared formula, the container should be sealed and stored in the refrigerator and used within 24 hours. Clients receiving continuous tube feedings should have gastric residuals checked every 4 to 6 hours.
A nurse is caring for an adult client who ate a chicken breast and drank a glass of water. There are 60 grams of protein in the chicken breast. Calculate the energy intake, in kilocalories, for this food. Record your answer using a whole number.
240 Explanation: To calculate total energy intake for a protein, multiply the total grams of the protein and multiply it times 4 kilocalories.
A nurse performing a nutritional assessment determines the BMI of a 5'11" (180 cm) male client who weighs 180 pounds (82 kg). What would be the BMI for this client?
25.1 Explanation:BMI is equal to:weight in kg/height in m2.
A nurse administers a continuous tube feeding via an NG tube. The nurse must check for residual every:
4 to 6 hours Explanation: Check for residual before each feeding or every 4 to 6 hours during a continuous feeding, according to institutional policy. This is implemented to identify delayed gastric emptying. Research suggests continuing the feedings with residuals up to 400 mL. If greater than 400 mL, the nurse should confer with the physician or hold feedings according to agency policy.
The nurse calculates the intake of a client who received a bolus tube feeding of 250 ml. The nurse administered 60 ml of water prior to the feeding and 60 ml of water after the feeding. The nurse administered crushed medications in 45 ml of water. Calculate the amount of fluid, in milliliters, the client received. Record your answer using a whole number.
415 Explanation:The nurse calculates fluid intake for a client who receives tube feedings to ensure adequate hydration and to avoid too much fluid at one time. 60 ml of water + 250 ml of tube feeding + 60 ml of water + 45 ml of crushed medications in water = 415 ml
The nurse is caring for four older adult clients. Which does the nurse identify at highest risk for cardiometabolic syndrome?
59-year old with bust, abdomen, and hips of similar proportion Explanation: Waist circumference and obesity are linked with cardiometabolic syndrome. The client with an abdomen that mirrors bust and hip circumference is at highest risk. The other clients are not at as high of a risk.
A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first?
Aspirate stomach contents and check pH. Explanation:Nasogastric tube placement should be checked before flushing, giving medications, or feeding. After placement has been ensured, the gastric residual should be checked, the nasogastric tube should be flushed as ordered, and the tube feeding administered.
The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?
Assess when client generally eats meals. Explanation:There are many reasons a client may refuse food that is served. The nurse should assess for food preferences, when the client generally eats, whether the client has digestive concerns, and cultural beliefs about foods. Leaving the client alone to eat, or simply delegating feeding, does not encourage intake. The client does not need an appetite stimulant until a full assessment has been conducted and other interventions have been implemented.
A nurse provides discharge education for a client diagnosed with ketosis. Which nutrient would be added to this client's diet?.
Carbohydrates Explanation:Ketosis is the catabolism of fatty acids that occurs when an individual's carbohydrate intake is not adequate; without adequate glucose, the catabolism is incomplete and ketones are formed, resulting in increased ketones. Proteins, fats, and minerals breakdown does not cause ketosis.
A nurse is preparing to administer medication to a client who is unable to swallow due to esophagitis. Upon review of the client's history, which condition would the nurse identify as contributing to the client's esophagitis?
Chronic vomiting Explanation: Esophagitis, an inflammation of the esophagus, can result from burns, poisons, infections, or chronic vomiting. It causes discomfort and impairs swallowing. Cholecystitis is an inflammation of the gallbladder that is usually caused by the presence of gallstones. Inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, greatly affects absorption of nutrients and water from the intestine. The intestinal inflammation results in severe diarrhea. Low blood pressure or abnormal change in blood pressure can lead to hypotension, not esophagitis.
A client who is receiving tube feedings has developed diarrhea. Which nursing intervention is appropriate?
Consult with the health care provider about using a milk-free formula. Explanation: The nurse will consult with the health care provider about using a milk-free formula since milk can induce diarrhea. Other interventions do not address the problem of diarrhea.
The nurse is teaching an older adult client how to administer tube feedings at home. Despite several interventions, the client cannot provide a return demonstration. Which nursing action is appropriate?
Contact home health services for a home health nurse. Explanation: A home health nurse can be of assistance if a client is afraid or unable to self-administer tube feedings. Other actions are inappropriate and do not effectively address the client's inability to demonstrate the task.
The nurse has assessed 100 mL of gastric residual after completing a tube feeding. What is the appropriate nursing action?
Document the assessment finding. Explanation:Gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube-feeding volume. This finding is normal and should be documented. The other actions are inappropriate based on the normal finding.
The nurse researches factors that may alter nutrition. Which statements accurately describe factors that influence nutritional status? Select all that apply.
During pregnancy and lactation, nutrient requirements increase. Nutritional needs per unit of body weight are greater in infancy than at any other time in life. Men and women differ in their nutrient requirements. The nurse found that during pregnancy and lactation, nutrient requirements increase. The nurse would also note that nutritional needs per unit of body weight are greater in infancy than at any other time in life. The nurse would find that men and women differ in their nutrient requirements. Trauma, surgery, and burns increase nutrient requirements. The BMR decreases with each decade in adulthood. The caloric needs of the older adult decrease, not increase.
The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake?
Encourage his daughter to prepare food at home and bring it to the client. Explanation:The nurse should solicit food preferences and encourage favorite foods from home, when possible. Be sure the foods look attractive and the eating area is free of odors, clutter, and distractions during mealtime. Provide small, frequent meals to avoid overwhelming the client with large amounts of food.
Carbonated sodas (such as Coca-Cola) are effective to clear a clogged feeding tube.
False
A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed?
Hematocrit 35% Explanation:The hematocrit level of this client is low. Normal hematocrit is 40%-50%. The normal value for hemoglobin is 12-18 mg/dL. The normal value for transferrin is 240-480 mg/dL. The normal blood urea nitrogen is 17-18 mg/dL.
Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?
If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. Explanation: The nurse would measure the volume and pH of the aspirated fluid, then flush the tube with water. The nurse would not place the client in Trendelenburg position as this could lead to reflux of the feeding from the stomach and possibly cause aspiration of the solution into the lungs. The nurse would not use a small syringe or continue to instill air until fluid is aspirated.
As a nurse is aspirating the contents during a tube feeding, the nurse finds that the tube is clogged. What would be appropriate nursing interventions in this situation? Select all that apply.
If necessary, replace the tube. Ensure that adequate flushing is completed after each feeding. Use warm water and gentle pressure to remove clog. The nurse would use warm water and gentle pressure to remove the clog. The nurse would replace the tube, if necessary. The nurse would ensure that adequate flushing is completed after each feeding. It is not evidence based practice to flush the feeding tube with a carbonated beverage. The nurse would not use a stylet to unclog the tube. This could cause damage to the feeding tube. The nurse would not administer an antiemetic to the client because the tube is clogged. This would not help the situation.
Which is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?
If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. Explanation:Warm water and gentle pressure, not a stylet, should be used to unclog a tube. If a large amount of residue is accidentally aspirated, the physician should be notified. If the client is nauseated, the head of the bed should remain elevated and an antiemetic administered as prescribed. The tube should be in the stomach, not the esophagus.
In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate?
Infection Explanation:Factors that increase a person's basal metabolic rate (BMR) include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones (epinephrine and thyroid hormones). Aging, prolonged fasting, and sleep all decrease BMR.
The nurse is teaching a class about caloric intake. Which statement should the nurse use to describe why weight loss may occur when a client has an infection?
Infection increases the basal metabolic rate and causes more calories to be utilized. Explanation: Dietary patterns should be adjusted to maintain a balance between caloric intake and energy expenditure. Basal metabolism is the amount of energy required to carry out involuntary activities at rest (e.g., breathing, circulating blood, maintaining body temperature). Men usually have a higher basal metabolic rate (BMR) than do women because of their proportionally greater muscle mass. Other factors, such as growth, infection, fever, stress, and extreme environmental temperatures, can increase BMR. Perspiration does not burn calories. Diarrhea can cause a lack of nutrients to be absorbed, but not all infections cause diarrhea. An increased respiratory rate is not known to increase BMR.
The nurse is teaching a new mother who had decided to breastfeed her infant. What nutrient must be supplemented by the mother after the first four months of breast feeding?
Iron Explanation:Full-term healthy babies receive enough iron from their mothers in the third trimester of pregnancy to last for the first four months of life. The nurse should teach the mother that human milk contains little iron, so infants who are exclusively breastfed are at increased risk of iron deficiency after four months of age. Bottle-fed babies will receive all of the necessary nutrients from the formula or cereal. Vitamin C, calcium and protein do not need to be supplemented as the breast milk has a sufficient amount.
A nurse is caring for a client who has a vitamin B12 deficiency. Which food would the nurse recommend to help with this deficiency?
Liver Explanation: The best foods from which to obtain B12 include organ meats and seafood. Pork provides thiamin. Cantaloupe provides vitamin B6; broccoli provides vitamin C.
While preparing clients for bedtime, the nurse finds the visiting family members affected the environment. Which action by a family member will make the nurse determine that the family needs additional teaching?
Lowered head of bed to 15° of client with nasogastric feeding tube Explanation:Individuals with nasogastric tubes should remain with the head of the bed at least 30 degrees due to increased risk of gastric reflux related to the dilation of the cardiac sphincter. This in turn greatly increases the risk of aspiration. The other actions should not be concerning because they would increase the safety of the client.
A nutritionist helps to plan a diet for a client with diabetes. Which food is a carbohydrate that should be included to help improve glucose tolerance?
Oatmeal Explanation:Oatmeal is a water-soluble carbohydrate that helps improve glucose tolerance in diabetics. Milk, eggs, and nuts are proteins.
A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James?
Overweight Explanation:A body mass index (BMI) between 25 and 29.9 is considered overweight.
A client with a recent diagnosis of stroke has swallowing difficulties. Which type of food preparation would facilitate the nutrition of this client?
Pureed diet Explanation: Pureed diets are indicated for clients who have significant problems chewing and/or swallowing. Liquid diets are not meant for long-term use and may not provide complete nutrition. A chopped diet can be helpful for those who have difficulty chewing.
A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals?
Small intestine Explanation: Most absorption of digested food and minerals occurs in the small intestines. The stomach is responsible for storing food, secreting digestive enzymes, and digestion. The large intestine forms feces and absorbs water to regulate the consistency of stool. The digestive function of the liver is the production of bile.
The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?
Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. Explanation:Clients who have dysphagia need to eat slowly and be continually observed for signs of aspiration.
A client receiving tube feedings has a gastric residual of 500 ml. Which nursing intervention is most appropriate?
Stop the infusion. Explanation: Gastric residual volumes (GVR) in the range of 200 to 500 mL should raise concern and lead to the implementation of measures reducing risk of aspiration. If the gastric residual is high, the feeding is stopped and the gastric residual is rechecked every 30 minutes until it is within a safe volume for resuming the feeding. Therefore, other answers are incorrect.
The nurse is preparing to check gastric residual for a client who had a tube feeding. After washing hands and donning gloves, what is the nurse's first action?
Stop the tube-feeding infusion. Explanation:The nurse will first stop the tube-feeding infusion and then continue to aspirate fluid, measure, and reinstill the aspirated fluid before reporting excessive amounts to the health care provider.
A nurse is preparing a presentation for a local community group on healthy nutrition using information from the USDA's website, ChooseMyPlate.gov. Which recommendation would the nurse be least likely to include?
Switching to whole milk Explanation:According to the ChooseMyPlate.gov food guide, individuals should switch to fat-free or low-fat (1%) milk, monitor portion sizes, drink water instead of sugary drinks, and make one-half the plate for fruits and vegetables
The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse?
The new nurse places the client in the left lateral recumbent position. Explanation:The client's head should be elevated 30 to 45 degrees. All of the other actions are correct and would not require intervention by the charge nurse.
A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?
To rest the gastrointestinal tract and promote healing Explanation: Withholding food may be indicated in the following situations: to rest the gastrointestinal tract to promote healing, clear the gastrointestinal tract of contents before surgery or diagnostic procedures, prevent aspiration during surgery or in high-risk clients, give normal intestinal motility time to return, treat severe vomiting or diarrhea, and to treat medical problems, such as bowel obstruction or acute inflammation of the gastrointestinal tract. Withholding food does not cause gas to accumulate or increase the amount of mucus in the bowel.
A client diagnosed with anemia is prescribed Vitamin B12 injections. In addition, which food(s) would the nurse encourage? Select all that apply.
lean steak milk yogurt saltwater fish Explanation:Cyanocobalamin, otherwise known as vitamin B12, is found in lean meats, milk and dairy products, and saltwater fish and oysters. It is not found in high concentrations in foods like peas or butter.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?
Try to ensure that the client's food is attractive and sufficiently warm. Explanation: Food in the health care setting can often be unattractive and cool. Ensuring that it is appealing to the eyes and presented at the correct temperature can stimulate the client's appetite. Meals should be small and more frequent, not less frequent and larger. Supplements may be nutritionally necessary, but these do not act to increase the client's appetite.
A client has a history of long-term alcohol use. Which nutrient would need to be required in increased amounts?
Vitamin B Explanation:The use of alcohol depletes the production of B vitamins in the liver; thus, they would need to be replaced. Calcium is a mineral that is an essential part of bones and teeth. Vitamin C, also known as ascorbic acid and L-ascorbic acid, is a vitamin found in food and used as a dietary supplement. The disease scurvy is prevented and treated with vitamin C-containing foods or dietary supplements. Thiamin is just of the B vitamins that would need to be replaced due to the depletion by alcohol. The other elements of the B Vitamins include the following: B1 Thiamin, B2 Riboflavin, B3 Niacin, B5 Pantothenic Acid, B6 Pyridoxine, B7 Biotin, B9 Folic Acid, and B12 Cobalamin.
A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?
Vitamin K Explanation: Specific foods may interact with medications, altering the effectiveness of the drug. Vegetables high in vitamin K decrease the effectiveness of the commonly used anticoagulant warfarin. Calcium, potassium, and Vitamin C do not interact with warfarin.
The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective?
When I take my medication, I will eat a banana or take it with a glass of orange juice." Explanation:The client demonstrates that the teaching was effective by identifying bananas and orange juice as foods rich in potassium. The desired effect of the medication is to excrete sodium to avoid the accumulation of fluid in the lungs. To increase the amount of salt in the diet would be counterproductive. Dairy products such as milk and cheese are not potassium-rich foods. Eating small frequent meals versus three meals per day is irrelevant in increasing potassium level.
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?
a client who has a fever Explanation:A client who has a fever would have an increased BMR. The energy needs of the body are increased due to the client's fever. The BMR is decreased in an older adult client, a client who is fasting, and a client who is asleep.
Which client will have an increased metabolic rate and require nutritional interventions?
a person with a serious infection and fever Explanation: Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. As the body attempts to repair the infection, there is a higher metabolic need and rate occurring. Aging, prolonged fasting, and sleep decrease metabolic rate.
What is the most reliable method for verifying the correct placement of a nasogastric tube?
a radiographic exam that can confirm position
A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?
anorexia Explanation:The nurse should document the loss of appetite following prolonged illness as anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal sensations.
A nurse who is planning a diet for a client who has anorexia chooses nutrients that supply energy to the body. Which nutrients are these? Select all that apply.
carbs protein lipids Explanation:Carbohydrates, protein, and lipids (fats) are the nutrients that supply energy. Vitamins, minerals, and water do not supply energy, but are necessary for balanced nutrition.
The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply.
cured ham table salt bacon Explanation: Sodium is found in higher concentrations in table salt, bacon, and processed meats. The other choices do not have a high concentration of sodium.
The nurse is caring for a client with excessive diarrhea who requires tube feeding. Which type of formula does the nurse anticipate will be ordered?
fiber-containing Explanation:The nurse anticipates that the client with excessive diarrhea will need fiber-containing formula to normalize bowel function. Standard isotonic formula is used for clients with normal digestion and absorption. Partially hydrolyzed formula provides nutrients in simple form that require little or no digestion for clients with impaired digestive processes.
A nurse is assessing the volume of liquid nutrition that has been tube-fed to a client. What will happen if the volume of feeding exceeds the client's physiologic capacity?
gastric reflux Explanation: Overfilling the client's stomach can cause gastric reflux, regurgitation, vomiting, aspiration, and pneumonia. Exceeding the volume of feeding beyond a client's physiologic capacity does not lead to diarrhea, pallor, or obesity. As a rule of thumb, the gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube-feeding volume.
A client with nonhealing wounds requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
high-protein Explanation: The nurse anticipates that the client with nonhealing wounds will need a formula that is high in protein and other nutrients to support tissue integrity and healing. Other formulas do not provide this type specific of nutrition.
A nurse is caring for a young client with vitamin C deficiency. Which client history finding(s) is related to the deficiency? Select all that apply.
increased susceptibility to infection retardation of growth and development joint pains and anemia Explanation:Signs of vitamin C deficiency are increased susceptibility to infection, retardation of growth and development, joint pain, anemia, and inadequate formation of collagen (poor wound healing). Vitamin C is an antioxidant that protects vitamins A and E from excessive oxidation. However, excessive doses of vitamin C are not advised because of the possibility of kidney stone formation and gastrointestinal disturbances.
A nurse is caring for a young adult female client who has a folic acid deficiency. When educating the client about this condition, the nurse would include a discussion about the client's increased risk for:
neural tube deficits in the fetus. Explanation: Folic acid deficiency in pregnant women can lead to neural tube deficits like spina bifida in the fetus. Because fetal neural development begins so early in pregnancy, women in their childbearing years must have adequate folic acid intake. Deficiency in vitamin D intake leads to inadequate absorption of calcium and phosphorus, and a deficiency of mineralization in bones and teeth. Increased hemolysis of red blood cells, poor reflexes, impaired neuromuscular functioning, and anemias are signs of vitamin E deficiency, not folic acid deficiency.
A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?
normal Explanation: Normal blood glucose is 80 to 110 mg/dL (4 to 7 mmol/L).
An unconscious client has been receiving complete calorically-dense liquid nutrition via a nasointestinal tube at a continuous drip for the past 4 days. Which action should the nurse prioritize after receiving the laboratory results for this client?
notify the health care provider Explanation:The glycated hemoglobin (A1c) is high and suggests this client has diabetes. A normal result should be less than 7% (0.07). The health care provider should be notified so further testing can be conducted and feeding formula changed or the client given insulin. The other test results are all within normal limits.
The nurse is reporting for work and notes each of the nurse's assigned clients have a percutaneous endoscopic gastrostomy (PEG) tube inserted. Which client should the nurse prioritize care for as the shift starts?
residual of 210 ml Explanation:As a rule of thumb, the gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube feeding volume. If the residual is more than 200 mL, the feeding should be delayed and residual rechecked in 30 minutes. The nurse should ensure the feeding has been stopped and note what time the residual should be rechecked. Bowel sounds should be at least 5 per minute and a respiratory rate of 18 breaths/min and unlabored are within normal limits. The client with the slightly elevated temperature would be the next client of the nurse to assess.
After a teaching session regarding dietary choices of carbohydrates, which client responses indicate correct understanding of the foods to limit in the diet? Select all that apply.
rice wheat germ corn on the cob apple Explanation:Sources of carbohydrates include cereals and grains such as rice, wheat and wheat germ, oats, barley, corn, and corn meal; fruits and vegetables; and sweeteners. Lean red meat is a protein source versus a carbohydrate.
The nurse is helping a client, who wishes to increase Omega-3 fatty acids, to order breakfast. Which food will the nurse recommend?
salmon Explanation: Omega-3 fatty acids are found in fish such as salmon, halibut, sardines, olive oil, flaxseed, walnuts, and certain types of legumes. The other food choices do not contain Omega-3 fatty acids.
A 66-year-old woman has atrial fibrillation for which she is on warfarin therapy. She asks the nurse if she has any dietary restrictions. The nurse would need to monitor the client's intake of:
spinach. Explanation:Spinach is high in vitamin K.
Which nutrient does the nurse identify as appropriate for a client with a normal dietary order who is consuming 2000 calories daily?
total fat less than 65 g Explanation: Daily values (DVs) are calculated in percentages based on standards set for total fat, saturated fat, cholesterol, sodium, carbohydrate, and fiber in a 2,000-cal diet. Total fat should be less than 65 g; saturated fat should be less than 20 g; cholesterol should be less than 300 mg, and sodium should be less than 2400 mg.
A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin?
vitamin B12 Explanation:Vitamin B12 deficiency is most commonly found in vegetarians, particularly in strict vegans. Individuals who have such rigid dietary restrictions must take care to supplement this vitamin.
A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?
vitamin D Explanation:Severe vitamin D deficiency manifests as rickets, osteomalacia, poor dentition, and tetany.
The nurse is preparing to administer a client's tube feeding. How should the nurse position the client prior to beginning the infusion?
with the head of the bed at least 30 to 45 degrees Explanation:Tube feedings should be administered with the head of the client's bed at least 30 to 45 degrees, or as near to normal eating position as possible. Side-lying, low-lying, and supine positions would constitute a risk of aspiration.
A student is following current recommendations for assessing tube placement. A staff nurse says, "Oh, just insert air and listen for a 'whoosh' sound." How would the student respond?
"That procedure has been found to be unreliable." Explanation:Some clinicians remain reluctant to abandon the auscultatory method of checking tube placement. This procedure has proven unreliable and may result in tragic consequences if used as the sole indicator of tube placement.
The nurse is conducting a client health history interview and notes the client is taking atorvastatin. This observation should prompt the nurse to ask the client which question first?
"When did you last have your cholesterol levels checked?" Explanation:Atorvastatin is a commonly prescribed HMO-COA reductase inhibitor. This classification of medication is taken to reduced blood cholesterol levels. It would be relevant to this observation for the nurse to follow with a question about the last time the client had serum triglyceride levels assessed to determine efficacy of the medication. Carbohydrates are not known to have a direct effect on increasing serum cholesterol levels. While it is important for the nurse to understand the client's nutritional intake and habits, this question would not be prioritized after noting that the client has this medication listed in the drug profile. Multivitamins provide supplementation for vitamin deficiencies but do not have a direct impact on a client's serum cholesterol levels. Overall, vegetarians have a lower incidence of colorectal cancer and fewer problems with obesity and diseases associated with a high-fat diet. Although the nurse can certainly inquire about what type of diet the client habitually consumes, this question does not directly relate to the observation that an antitriglyceride medication is being taken by the client.
Which nutritional guideline should a nurse provide to a client who is entering the second trimester of her pregnancy?
"You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." Explanation: Nutrient needs during pregnancy increase in order to support growth and maintain maternal homeostasis, particularly during the second and third trimesters. During the last two trimesters, women of normal weight need approximately 300 extra calories per day. Key nutrient needs include protein, calories, iron, folic acid, calcium, and iodine. It would be inaccurate to encourage the client to maximize calorie intake, take supplements, and emphasize organic foods.
A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?
145 lb/ 65.7 kg Explanation:A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet.
A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?
Ensure the head of the bed is elevated. Explanation:The head of the bed should be elevated before giving medications or performing a tube feeding. Following this, the placement of the tube should be checked, aspirate the gastric contents with a syringe, and then flush the tube with the ordered amount of water.
A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client?
Drink juice for majority of fluid intake. Explanation:Water should comprise the majority of fluid intake. The remainder should come from food sources such as fruit or 100% fruit juices.
A nurse is caring for a client with a wound infection. The dietician has prescribed a diet rich in vitamin A. The client asks the nurse, "Why do I need vitamin A?" The nurse integrates an understanding of which rationale as a major reason when responding to the client?
It helps maintain healthy epithelium. Explanation: Vitamin A is important for maintenance of healthy epithelium, maintenance of normal vision (especially in dim light), promotion of normal skeletal and tooth development, and promotion of normal cellular proliferation. Vitamin D promotes mobilization of calcium and phosphorus from bone, renal reabsorption of calcium, normal mineralization of bone and cartilage, intestinal absorption of calcium, and maintenance of calcium extracellular fluid for normal muscle contraction.
The nurse has inserted a nasogastric tube for a client who requires enteral feeding. After completing tube insertion, what is the best method for the nurse to confirm tube placement prior to starting the feed?
Send the client for an abdominal x-ray. Explanation:Although several bedside physical assessment methods such as auscultating the abdomen while instilling air and testing the pH of aspirated liquid have been used by nurses and may still be practiced to determine the distal location of a nasogastric tube, theses methods do not always provide credible evidence. Current data indicates that testing the pH of aspirated fluid can be unreliable because the pH can be falsely altered by the aspiration of swallowed alkaline saliva, refluxed acidic gastric secretions, and medications that make gastric secretions less acidic. In addition, auscultation over the abdomen while air is instilled is known to cause pseudo confirmatory gurgling when air enters the esophagus or small intestine, thus misinterpreting a gastric location of the tube's tip. The only evidence-based methods for determining the distal location of a nasogastric tube include obtaining an abdominal x-ray after its initial insertion and monitoring the external tube length (the "X" marked component of the nose-to-ear-to-xiphisternum [NEX] measurement to the proximal end of the tube) after radiographic confirmation.
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?
overweight Explanation: A client with a BMI below 18.5 should be considered underweight. A client with a BMI of 18.5 to 24.9 is considered to be at a healthy weight. A client with a BMI of 25 to 29.9 is considered overweight; a client with a BMI of 30 or greater indicates obesity. A BMI greater than 40 is considered extreme obesity.
A nurse calculates the BMI of a client during a general survey as 26. Under which category would this client fall?
overweight Explanation: This client has a BMI of 26, which falls in the category of overweight: 25.0 to 29.9. The other BMI values are: underweight, <18.5; normal, 18.5 to 24.9; obesity class I, 30.0 to 34.9; obesity class II, 35.0 to 39.9; and extreme obesity, 40.0+.
The nurse is providing education to a client who has been diagnosed with iron-deficiency anemia. The client has asked the nurse to review a list of preferred foods to determine which should be included more often in the diet. Which food(s) will the nurse encourage the client to increase in the diet? Select all that apply.
roasted chicken breast lean hamburgers kale salad spinach smoothies In addition to medicinal iron, clients who have iron-deficiency anemia need to eat a diet that is rich in dietary iron. The foods on the client's preferred list should include meats (e.g., lean hamburgers), poultry (e.g., roasted chicken breast), fish, leafy greens (e.g., kale salad and spinach smoothies), legumes, and iron-enriched pastas and grains. Dairy products such as yogurt are not a source of dietary iron. Cucumber and tomato do not provide a significant source of dietary iron.
