Foundations Chapter 45 Nutrition 2
Which action is the nurse most unlikely to perform during blood glucose monitoring of a patient? 1 Using the first drop of blood obtained after puncturing 2 Instructing the patient to perform hand hygiene with soap and warm water 3 Positioning the patient comfortably in chair or in semi-Fowler's position in bed 4 Holding the area to be punctured in a dependent position without massaging the site
1 The nurse should not use the first drop of blood obtained by puncturing because the first drop of blood may contain more serous fluid than blood cells. The other actions are parts of blood glucose monitoring. The patient should be instructed to perform hand hygiene with soap and warm water. The patient is positioned comfortably in chair or in semi-Fowler's position in bed. The area to be punctured should be held in a dependent position to increase blood flow to the area before puncture. Massaging may hemolyze the specimen and introduce excess tissue fluid, thereby causing inaccurate readings.
A 16-year-old patient is having symptoms of malnutrition even though the patient eats a well-balanced diet. The laboratory reports of the stool samples reveal undigested fats. What could be the organs involved in malnutrition? Select all that apply. 1 Stomach 2 Liver 3 Gall bladder 4 Submandibular gland 5 Pancreas
1, 2, 3, 5 Digestion of fat starts in the stomach. The partially digested food goes into the duodenum where the fats are emulsified by the bile juice. The bile juice is secreted by the liver and stored by the gall bladder. The emulsified fat is easily digested by pancreatic lipase. Ptyalin, or salivary amylase, from the salivary gland is the first enzyme that starts the digestion of carbohydrates in the mouth itself. The submandibular gland is a major salivary gland and has no role in the digestion of fats.
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. 1 Schedule a 30-minute rest period before eating. 2 Position the patient in an upright, seated position. 3 Have the patient flex the head slightly to a chin-down position. 4 Feed the patient thin fluids and juices. 5 Allow the patient time to empty the mouth before each spoonful.
1, 2, 3, 5 Feeding should be carefully performed to prevent aspiration pneumonia. The act of chewing and swallowing may be a difficult task in a patient with dysphagia and may cause fatigue. Therefore, the patient should be given a 30-minute rest period before the meal. Positioning the patient upright in a seated position prevents the aspiration of food. Having the patient flex the head slightly to a chin-down position prevents aspiration. Enough time should be given to the patient to chew the food properly and swallow it. Thin juices are difficult to swallow. Instead, thick fluids and pureed foods should be provided.
A dietitian advised the mother of a school-age child to include complete proteins in the child's diet to promote growth. Which food items should the nurse instruct the mother to include in the diet? Select all that apply. 1 Fish 2 Beans 3 Cheese 4 Cereals 5 Soybeans
1, 3, 5 Complete proteins, also called high-quality proteins, are those proteins that contain all essential amino acids in adequate amounts to promote growth. Fish, cheese, and soybeans are examples of complete proteins. These food items contain balanced amounts of all amino acids required for growth and development. Beans and cereals are incomplete proteins and are deficient in one or more essential amino acids.
An infant needs 330 kcal of energy per day. How many ounces of commercial formula does the infant need to drink per day in order to meet the requirement? Record your answer using one decimal place. ________ oz
16.5 The infant should drink 16.5 oz of commercial formula per day in order to get 330 kcal of energy per day. Commercial formulas usually provide 20 kcal/oz. Therefore, to get 330 kcal of energy per day the infant should drink 330 / 20 = 16.5 oz of commercial formula.
Which enzyme do the chief cells of the stomach secrete? 1 Secretin 2 Pepsinogen 3 Intrinsic factor 4 Cholecystokinin
2 The chief cells of the stomach secrete the enzyme pepsinogen. The small intestine secretes the hormones secretin and cholecystokinin. The parietal cells secrete intrinsic factor.
To digest starch, which enzyme does the pancreas secrete? 1 Lipase 2 Amylase 3 Elastase 4 Carboxypeptidase
2 To digest starch, the pancreas secretes amylase. The pancreas secretes lipase to break down emulsified fats and elastase and carboxypeptidase to break down proteins.
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. 1 Body mass index (BMI) of 26 2 Poor muscle tone 3 Smooth, supple skin 4 Hair loss 5 Pale conjunctiva
2, 4, 5 Malnourishment refers to the condition when nutritional intake is inadequate to meet the metabolic demands of the body. Inadequate nutrition can affect all systems of the body. The musculoskeletal system may be affected, leading to poor muscle tone. The integumentary system may be affected, leading to hair loss. The production of red blood cells may decline, leading to anemia. Low hemoglobin is evident as pale conjunctiva and mucous membrane. Body mass index measures weight corrected for height. A BMI between 25 and 30 indicates the patient is overweight. A smooth and supple skin indicates adequate nutrition and a healthy fluid balance. Nutritional deficiency may lead to dry, scaly skin.
In which position should the nurse place the patient to conduct blood glucose monitoring? 1 Prone 2 Side-lying 3 Semi-Fowler's 4 Trendelenburg's
3 The nurse should place the patient in a semi-Fowler's position when conducting blood glucose monitoring. The prone, side-lying, and Trendelenburg's positions are patient positions for other procedures.
A patient of normal weight asks the nurse for dietary guidelines for maintaining her weight. What does the nurse teach the patient? 1 "Eat lots of lean meats." 2 "Avoid foods that are rich in potassium." 3 "Consume fats containing unsaturated fatty acids." 4 "Keep total fat intake between 15 to 20 percent of total calories."
3 The nurse should teach the patient to consume fats containing unsaturated fatty acids such as polyunsaturated or monounsaturated fatty acids. The patient should eat lean meats in moderate, not high, amounts. The patient should consume, not avoid, foods that are rich in potassium. The patient's total fat intake should be between 20 and 35 percent of total calories.
A patient is on parenteral nutrition. For which complications should the nurse look? Select all that apply. 1 Pulmonary aspiration 2 Delayed gastric emptying 3 Hyperglycemia 4 Electrolyte imbalance 5 Hypercapnia
3, 4, 5 Complications of parenteral nutrition include hyperglycemia, electrolyte imbalance, and hypercapnia. Hyperglycemia may be caused by formulas rich in carbohydrates and fats. Electrolyte imbalance may result from consuming concentrated formulas. Hypercapnia is usually seen in ventilator-dependent patients. Pulmonary aspiration and delayed gastric emptying are complications of enteral nutrition.
The nurse is administering an enteral feeding to a patient who must remain in a supine position. Which nursing action is appropriate? 1 Placing the patient in Sim's position 2 Placing the patient in a lithotomy position 3 Placing the patient in high-Fowler's position 4 Placing the patient in reverse Trendelenburg's position
4 When administering an enteral feeding to a patient who must remain supine, the nurse should place the patient in reverse Trendelenburg's position; keeping the patient's head elevated helps prevent aspiration. The Sim's, lithotomy, and high-Fowler's positions will not allow the patient to remain supine.
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? 1. Full liquid 2. Low residue diet 3. Mechanical soft 4. Pureed diet 5. Clear liquid
5, 1, 4, 3, 2 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.
Which amino acid does the body not synthesize? 1 Lysine 2 Alanine 3 Asparagine 4 Glutamic acid
1 The body does not synthesize lysine, which is an indispensable amino acid that should be part of a healthy diet. Alanine, asparagine, and glutamic acid are dispensable amino acids, which are synthesized by the body.
Which term describes the suggested intake for individuals based on experimentally determined estimates of nutrient intakes? 1 Adequate intake 2 Tolerable upper intake level 3 Estimated average requirement 4 Recommended dietary allowance
1 Adequate intake is the suggested intake for individuals based on experimentally determined estimates of nutrient intakes. The tolerable upper intake level is the highest level of nutrient intake that likely poses no risk of adverse health events. The estimated average requirement is the recommended amount of a nutrient that appears sufficient to maintain a specific body function for 50 percent of the population on the basis of age and gender. The recommended dietary allowance is the average needs of 98 percent of the population but not the exact needs of an individual.
What test should be performed to confirm the correct placement of a nasogastric (NG) feeding tube before the start of feedings? 1 An x-ray study 2 Auscultation of the abdomen 3 Assessment of stomach content pH 4 Assessment of residual stomach contents
1 An x-ray study is the most accurate confirmation method for ascertaining the exact placement of a nasogastric feeding tube and should always be done on initial tube insertion. Auscultation is unreliable. The pH of the fluid returned is more reliable than auscultation or residual assessment but not as certain as x-ray confirmation. Residual assessment is difficult to obtain with small-bore feeding tubes.
Which equipment should the nurse have available when testing a patient's blood glucose level? Select all that apply. 1 Lancet 2 Paper towel 3 Sterile gloves 4 Antiseptic swab 5 Catheter tip syringe
1, 2, 4 When testing a patient's blood glucose level, the nurse should have a lancet, paper towel, and antiseptic swab available. Clean, not sterile, gloves are also required for this procedure. A catheter tip syringe is needed to check gastric residual volume (GRV), not to monitor blood glucose levels.
Which pieces of equipment should the nurse have available to intubate a patient with a feeding tube? Select all that apply. 1 Towel 2 Tuning fork 3 Stethoscope 4 Reflex hammer 5 Water-soluble lubricant
1, 3, 5 The nurse should have a towel, stethoscope, and water-soluble lubricant available during the insertion, or intubation, of a feeding tube. A tuning fork and reflex hammer are required for other procedures.
The nurse is feeding a patient with dysphagia. Which action performed by the nurse during feeding may lead to aspiration? 1 The nurse raises the head of the bed to 90 degrees. 2 The nurse extends the patient's head to a chin-up position. 3 The nurse places the food on the stronger side of the mouth. 4 The nurse provides the patient with thicker fluids to drink.
2 A patient with dysphagia is at risk of aspiration if precautions are not taken during feeding. When positioning the patient for feeding, the nurse should keep the patient's head flexed in a chin-down position. This position promotes swallowing and prevents the food from entering the respiratory tract. The head of the bed should be raised at 90 degrees to prevent aspiration. The food should be placed in the stronger side of the mouth to facilitate swallowing. Thick fluids are easier to swallow than thin fluids and prevent aspiration.
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? 1 Raise the head of the bed to 90 degrees. 2 Turn the patient to left lateral decubitus position. 3 Notify the health care provider immediately. 4 Have the patient perform the Valsalva maneuver.
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 the integrity of the closed intravenous system also helps prevent an air embolus. Notifying the health care provider is important and would need to be done, although not immediately. Safety is the immediate priority, which the correct answer addresses.
What drug-nutrient interaction do aspirin and sodium bicarbonate have in common? 1 Decreased iron absorption 2 Decreased folic acid absorption 3 Decreased vitamin K absorption 4 Decreased vitamin C absorption
2 Both aspirin and sodium bicarbonate decrease the absorption of folic acid. Aspirin decreases the absorption of iron, vitamin K, and vitamin C whereas sodium bicarbonate does not.
The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? 1 A 55-year-old obese man recently diagnosed with diabetes mellitus 2 A recently widowed 76-year-old woman recovering from a mild stroke 3 A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery 4 A 46-year-old man recovering at home following coronary artery bypass surgery
2 Older adults who are homebound and have a chronic illness have additional nutritional risks. Frequently members of this group live 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.
The nurse sees the nursing assistive person (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? 1 The NAP fastens the tube to the gown with tape. 2 The NAP places the patient supine while giving a bath. 3 The NAP performs oral care for the patient. 4 The NAP elevates the head of the bed 45 degrees.
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.
Which nursing action is appropriate when removing an enteral feeding tube from the patient? 1 Placing the patient in low-Fowler position 2 Pulling the patient's tube steadily and smoothly 3 Straightening the end of the patient's tube securely 4 Instructing the patient to take a deep breath and exhale
2 When removing an enteral feeding tube from the patient, the nurse should pull the tube steadily and smoothly. The patient should be placed in high-Fowler's, not low-Fowler's, position. The end of the patient's tube should be kinked, not straightened. The patient should be instructed to take a deep breath and hold it, not exhale.
Which substances comprise the referenced daily intakes (RDIs) that the U.S. Food and Drug Administration (FDA) has established? Select all that apply. 1 Fiber 2 Proteins 3 Vitamins 4 Minerals 5 Total fat 6 Carbohydrates
2, 3, 4 Proteins, vitamins, and minerals comprise the U.S. Food and Drug Administration (FDA) referenced daily intakes (RDIs). Fiber, total fat, and carbohydrates comprise the FDA daily reference values (DRVs) Both RDIs and DRVs make up the daily values used on food labels.
Which are the rights the nurse should implement to enhance safety for a patient who is prescribed enteral feedings? Select all that apply. 1 Dose 2 Tube 3 Patient 4 Formula 5 ENFit adapter
2, 3, 4, 5 The rights the nurse should implement to enhance safety for a patient who is prescribed enteral feedings includes the right tube, patient, formula, and ENFit adaptor. The right dose, not enteral tube feeding administration, is a right of medication administration.
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. 1. Attempt to aspirate a clot. 2. Temporarily stop the infusion. 3. Use a thrombolytic agent if ordered or per protocol. 4. Flush the line with saline or heparin.
2, 4, 1, 3 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).
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? 1 Daily 2 Monthly 3 Three times per week 4 Every 3 months
3 A patient who has reached the maximum administration rate for the prescribed enteral feedings should be weighed three times per week. Weighing the patient daily is done until the maximum administration rate is achieved. Monthly weights or weigh-ins that occur every 3 months are too infrequent to allow the nurse to appropriately monitor the patient's weight.
What is the advantage of enteral feeding over parenteral feeding? 1 It is more satisfying for the patient. 2 It allows the patient to be ambulatory. 3 It maintains intestinal function and integrity. 4 It reduces the risk of foodborne illness
3 Enteral feedings maintain gastrointestinal (GI) function and integrity. Unfortunately, tube feeding does not offer taste or much satisfaction for the patient. Each method of tube feeding can allow some mobility, but usually patients have accompanying problems that would interfere. Formulas can contain bacteria or be contaminated if not prepared in clean conditions. Formulas should not be used for longer than 4 to 8 hours, and the tubing and bags should be changed daily.
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? 1 Starting the enteral feeding at a slow rate 2 Administering a milk-based formula 3 Verifying the placement of the tube through x-ray 4 Auscultating the bowel sounds before feeding
3 Following insertion of a tube for enteral feeding, the placement of the tube should be verified through an x-ray. This verification helps prevent complications such as pulmonary aspiration. Starting the enteral feeding at a slow rate helps to advance the feeding based on the patient's tolerance. Administering a milk-based formula does not help to prevent aspiration. Auscultating the bowel sounds helps to determine if the gastrointestinal tract is functioning; it does not help to ascertain the placement of the tube.
The nurse records the assessment findings of a patient. The findings are: Body mass index (BMI) 33, heart rate 72 beats/minute, pale conjunctivas, pink-colored gingiva, and spoon-shaped nails. Which is a sign of good nutrition in this patient? 1 BMI of 33 2 Pale conjunctivas 3 Pink gingiva in the mouth 4 Spoon-shaped nails
3 Pink gingiva is a sign of good blood circulation. It signifies adequate hemoglobin levels in the blood. A good hemoglobin level indicates a sufficient iron intake, which suggests good nutrition. A BMI of 33 indicates that the patient is obese. A pale conjunctiva is a sign of anemia. Spoon-shaped nails indicate iron-deficiency anemia. Nails should be firm and pink.
The nurse is teaching an infant's mother about the developmental needs of infants. What statement made by the mother indicates a need for further teaching? 1 "I should avoid giving my infant honey during the first year." 2 "I should avoid giving my infant cow's milk during the first year." 3 "I should avoid giving my infant soy-based formulas during the first year." 4 "I should avoid giving my infant corn syrup products during the first year."
3 Soy protein-based formulas are safe and good for infants, especially those who are allergic to cow's milk. The remaining statements indicate understanding. Honey should be avoided during the first year of an infant's life because it is a potential source of botulism toxin. Cow's milk should be avoided during the first year of an infant's life because it increases the risk of milk-product allergies and is a poor source of iron and vitamins C and E. Cow's milk is also too concentrated for an infant's kidneys to process. Corn syrup products should be avoided during the first year of an infant's life because, like honey, they are a potential source of botulism toxin.
Which nursing actions are appropriate when checking for gastric residual volume (GRV) before each enteral feeding? Select all that apply. 1 Discarding gastric contents 2 Flushing the tube with 50 mL of air 3 Flushing the tube with 30 mL of water 4 Holding the feeding for an aspirate volume of 525 mL 5 Pulling back slowly to aspirate total volume of gastric contents
3, 4, 5 When checking for GRV before each enteral feeding, the appropriate nursing actions include flushing the tube with 30 mL of water, holding the feeding for an aspirate volume of 525 mL, and pulling back slowly to aspirate the total volume of gastric contents. The nurse should return, not discard, the gastric contents. The nurse should flush the tube with 10 to 30 mL of air, not 50 mL.
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 According to the American Heart Association guidelines, 300 mg/day cholesterol intake is allowed in a therapeutic diet to reduce cholesterol levels.
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? 1 Micrococcus 2 Staphylococcus 3 Corynebacterium 4 Helicobacter pylori
4 Marshall and Warren (1984) 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.
A patient with arthritis develops iron-deficiency anemia. About what should the nurse ask the patient? 1 Alcoholic beverages 2 Stool softeners and laxatives 3 Caffeinated foods and beverages 4 Nonsteroidal anti-inflammatory drugs (NSAIDs)
4 NSAIDs decrease the level of vitamin C, which aids in the absorption of iron. These drugs also compete with folate and vitamin K and may cause gastritis. Excessive alcoholic beverage consumption can cause stomach irritation; alcohol would not be directly related to iron-deficiency anemia unless bleeding ulcers or gastritis were to occur. NSAID consumption, not stool softeners and laxative use, would be suspected in iron-deficiency anemia. Caffeinated foods and beverages can cause gastric irritation and discomfort but are not associated with iron-deficiency anemia.
By which process do particles move outward from an area of greater concentration to one of lesser concentration without the help of a special carrier? 1 Osmosis 2 Pinocytosis 3 Active transport 4 Passive diffusion
4 Passive diffusion is the process in which particles move outward from an area of greater concentration to one of lesser concentration without a carrier. In the process of osmosis, water moves through a semipermeable membrane to equalize the concentration pressures on both sides of the membrane. Pinocytosis is the process of an absorbing cell engulfing large molecules of nutrients when the molecules attach to the absorbing cell membranes. Active transport is the energy-dependent movement of particles from a region of greater concentration to a region of lesser concentration with the help of a special carrier.
Which nursing action is appropriate when providing care to a patient who is prescribed aspiration precautions? 1 Eliciting a gag reflex 2 Using a validated assessment tool 3 Providing a 60-minute rest period prior to meals 4 Elevating the head of the bed to a 90-degree angle
4 The nurse should elevate the head of the bed to a 90-degree angle prior to feedings for any patient who is prescribed aspiration precautions. Eliciting a gag reflex and using a validated tool are appropriate nursing actions during the patient's aspiration assessment but not for the patient who is already prescribed aspiration precautions. A rest period of 30, not 60, minutes prior to meals is appropriate for a patient who is prescribed aspiration precautions.
The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the steps of the procedure in the correct sequence. 1. Explain procedure and purpose to patient and/or family. 2. Clean puncture site with antiseptic solution. 3. Wick blood drop into test strip. 4. Check code on test strip vial. 5. Assess area of skin to be used as puncture site. 6. Read results and document in medical record. 7. Gently squeeze fingertip until a drop of blood appears.
5, 1, 4, 2, 7, 3, 6 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.
The weight of an infant is 8 kg. If the infant needs an energy intake of 100 kcal/kg of body weight per day, what should be the total energy intake of the infant per day? Record your answer using a whole number. ________ kcal
800 The total energy intake of the infant per day is 800 kcal. The infant needs an energy intake of 100 kcal/kg of body weight per day. Because the infant weighs 8 kg, the total energy intake per day should be 8 × 100 = 800 kcal.
The nurse is preparing a diet plan for a patient diagnosed with gluten intolerance. What food item can be included in the diet plan? 1 Wheat 2 Oats 3 Rice 4 Barley
3 Rice does not contain gluten and can be added to the diet plan. Gluten is present in wheat, rye, barley, and oats, so they should be avoided in patients with celiac disease or patients with gluten intolerance. Gluten can result in malabsorption and nutritional deficiencies in the patient.
Which nursing action is appropriate when providing care to a patient who experiences pulmonary aspiration due to enteral feedings? 1 Suctioning the airway 2 Conferring with a dietician 3 Flushing the tube with water 4 Instituting skin care measures
1 The patient who experiences pulmonary aspiration due to enteral feedings should have his or her airway suctioned by the nurse. Conferring with a dietician is appropriate for a patient who develops frequent diarrhea. Flushing the tube with water is appropriate for a patient whose enteral feeding tube is clogged. Instituting skin care measures is appropriate for a patient who develops diarrhea and is at risk for perianal excoriation.
The nurse is inserting a central catheter into a patient to provide parenteral nutrition (PN). The nurse places the patient in a left lateral decubitus position, and instructs the patient to hold her breath and bear down during catheter insertion. What is the most probable reason the nurse put the patient in that position and asked her to hold her breath and bear down? 1 It helps to prevent air embolism. 2 It promotes the patient's comfort. 3 It promotes lung expansion. 4 It prevents pulmonary aspiration.
1 An air embolism can occur when inserting a catheter for parenteral nutrition (PN). It can be prevented by placing the patient in a left lateral decubitus position, because the chances of air embolism are minimal due to the anatomic position of the heart. Holding the breath and bearing down is called the Valsalva maneuver. Performing the Valsalva maneuver helps to increase the venous pressure and prevent air from entering the bloodstream. The patient's position does not promote the patient's comfort nor does it promote lung expansion. It also does not help to prevent pulmonary aspiration; pulmonary aspiration is a complication of enteral nutrition and is not related to PN.
Which action is initially taken by the nurse to verify the correct position of a recently placed small-bore feeding tube? 1 Placing an order for x-ray film examination to check position 2 Confirming the distal mark on the feeding tube after taping 3 Testing the pH of the gastric contents and observing the color 4 Auscultating over the gastric area as air is injected into the tube
1 At present, the most reliable method for verification of placement of small-bore feeding tubes after initial placement 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 before use, but after the initial placement verification by x-ray should be done. 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.
What action is part of the assessment phase when caring for a patient diagnosed with malnutrition? 1 Determine the patient's nutritional energy needs. 2 Involve the patient's family when designing interventions. 3 Select nursing interventions consistent with therapeutic diets. 4 Reassess signs and symptoms associated with altered nutrition.
1 During the assessment phase of the nursing process for a patient diagnosed with malnutrition, the nurse needs to determine the patient's nutritional energy needs. The nurse involves the patient's family members in designing the intervention during the planning phase of the nursing process. Also during the planning phase, the nurse selects the nursing interventions consistent with therapeutic diets. During the evaluation phase, the nurse reassesses signs and symptoms associated with altered nutrition.
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? 1 The patient has retained a liter of fluids. 2 The patient has had a healthy weight gain. 3 The patient's kidney function has improved. 4 The patient has not passed urine for a long time.
1 In renal failure, kidneys may not be able to excrete the required amount of fluids from the body, resulting in fluid retention. An increase in body weight over a period of 24 hours indicates water retention in a patient with renal failure. Retention of 500 mL of fluids would cause an increase of one pound in body weight. Therefore, if there is an increase of 2 pounds in body weight, the patient has fluid retention of 1 liter. This weight gain is not considered healthy because it indicates that the kidneys are unable to excrete the additional fluids in the body. The weight gain indicates a deteriorating kidney function. The patient's not passing urine for a long time does not cause an increase in body weight. In addition, body weight is measured only after the patient has passed urine.
Which is the first nursing action when monitoring a patient's blood glucose level? 1 Performing hand hygiene 2 Turning on the glucometer 3 Choosing the puncture site 4 Removing the reagent strip from container
1 The first nursing action when monitoring a patient's blood glucose level is to perform hand hygiene. Hand hygiene limits the transfer of microorganisms. While turning on the glucometer, choosing the puncture site, and removing the reagent strip from the container are all appropriate nursing actions for this procedure, these will not be the first step for the nurse.
The nurse is feeding a patient with dysphagia. Which position of the patient should be avoided to reduce the risk of aspiration? 1 Supine 2 Sitting in a chair 3 High Fowler's position 4 Chin-tucked position
1 The patient should not be placed in a supine position, because the risk of aspiration is high. To prevent aspiration, the patient should be made to sit in a chair or in a Fowler's position. This position helps the patient to swallow properly and prevents the risk of food going into the airway. The chin-tucked position helps to prevent aspiration.
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? 1 Rechecking the GRV in 1 hour 2 Consulting with the patient's dietician 3 Placing the patient in a side-lying position 4 Discarding the GRV and administering the scheduled feeding
1 The priority nursing action in this situation is to hold the feeding and recheck the gastric residual volume (GRV) in 1 hour. The nurse should consult with the patient's health care provider, not the dietician, in this situation. The patient should be placed in an upright position, not a side-lying position. The GRV should be returned and the feeding held; discarding the GRV can cause fluid and electrolyte imbalances.
A patient needs enteral feedings via a nasoenteric tube. Which action does not take place during the assessment phase for this patient? 1 Explaining the procedure to the patient 2 Examining the abdomen of the patient 3 Asking the patient about food allergies 4 Evaluating the patient's nutritional status
1 When a patient needs to be administered enteral feedings via nasoenteric tube, the nurse explains the procedure to the patient during the planning phase, not assessment. Examining the patient's abdomen, asking the patient about food allergies, and evaluating the patient's nutritional status takes place during assessment.
A patient needs advice regarding diet to help in weight loss. Which food items suggested by the nurse contain significant amounts of fiber? Select all that apply. 1 Oats 2 Barley 3 Cornmeal 4 Cheese 5 Milk
1, 2, 3 Fiber in the diet does not contribute calories because it is not broken down by the digestive enzymes. Oats, barley, and cornmeal contain significant amounts of fiber. Cheese and milk are easily broken down and digested.
A postoperative patient is advised to take clear fluids. What types of fluids should the nurse provide to the patient? Select all that apply. 1 Tea 2 Coffee 3 Carbonated beverages 4 Vegetable juices 5 Blended cream soups
1, 2, 3 Some patients who are chronically ill or who have undergone surgery may need to resume their diet gradually. They are usually started on clear fluids and then progressed to other diets. Clear fluids include tea, coffee, and carbonated beverages. These fluids are easy to digest and do not leave any residue after digestion. Vegetables and blended cream soups are full liquids and are usually given once the patient is able to tolerate clear fluids.
Which food items contain gluten and should be avoided in patients with celiac disease? Select all that apply. 1 Wheat 2 Rye 3 Barley 4 Oats 5 Rice
1, 2, 3, 4 Celiac disease is characterized by malabsorption of gluten. Therefore, the patient should avoid food items containing gluten. Wheat, rye, barley, and oats are rich in gluten and should be avoided. Rice is wheat- and gluten-free and can be included in the diet.
The nurse is caring for a patient with dysphagia. Of what complications of dysphagia should the nurse be aware? Select all that apply. 1 Aspiration pneumonia 2 Dehydration 3 Decreased nutritional status 4 Weight loss 5 Gastrointestinal infection
1, 2, 3, 4 Dysphagia is difficulty swallowing. A patient who has difficulty swallowing may aspirate food while eating. Food in the respiratory tract can cause pneumonia. A patient with dysphagia may not be able to swallow liquids, thereby decreasing the fluid intake. It can result in dehydration. The patient may not be able to eat properly, which affects nutritional intake, and weight loss may occur. Dysphagia does not cause gastrointestinal infection.
The nurse is caring for a patient who is on tube feeding. What signs and symptoms suggest intolerance to feedings? Select all that apply. 1 High gastric residual 2 Nausea 3 Vomiting 4 Constipation 5 Cramping
1, 2, 3, 5
Which data should nurse document in the patient's medical record after the intubation of an enteral tube? Select all that apply. 1 Type of tube 2 Size of the tube 3 pH value of gastric aspirate 4 Location of the proximal end of the tube 5 Confirmation of tube placement by x-ray film
1, 2, 3, 5 After the patient is intubated with an enteral tube the nurse documents the type and size of tube inserted, the pH value of the gastric aspirate, and confirmation of tube placement by x-ray film. The location of the distal, not proximal, end of the tube should also be documented.
The nurse works at a weight loss clinic. A teenage girl approaches the nurse for advice on weight loss. Which instructions should the nurse give to the teenager to help reduce her weight? Select all that apply. 1 Engage in regular exercise. 2 Participate in outdoor sports. 3 Include physical activities in your daily routine. 4 Decrease carbohydrate content in the diet when exercising. 5 Ovoid excessive consumption of junk foods
1, 2, 3, 5 Regular exercise, physical activities, and sports are all essential for burning calories and reducing weight. Junk foods are excessively fatty, so these should be avoided. Carbohydrate content should be increased in the diet when exercising because carbohydrates are a major source of energy.
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. 1 Watery stool over the last day 2 An excessively snug external disk 3 Active bowel sounds in all quadrants 4 Lack of aspirate noted prior to feedings 5 Redness and irritation at the insertion site
1, 2, 5 Data that would necessitate further action by the nurse when providing care to a patient who is receiving enteric feeding with a gastrostomy tube inserted through the abdominal wall include watery stool, an excessively snug external disk, and redness and irritation at the insertion site. Watery stool often indicates the rate of the feeding is too fast. A disk that is too snug may cause skin breakdown. Redness and irritation at the insertion site can increase the risk for skin breakdown and infection. Active bowel sounds in all quadrants and lack of aspirate are normal findings that do not require interventions.
Which assessments should the nurse perform prior to inserting a nasoenteric tube for enteral feedings? Select all that apply. 1 Height 2 Weight 3 Apical pulse 4 Blood pressure 5 Hydration status
1, 2, 5 Prior to the insertion of a nasoenteric tube for enteral feedings, the nurse should assess the patient's height, weight, and hydration status. This information provides baseline information to measure nutritional improvement after enteral feedings are initiated. The nurse may take an apical pulse and blood pressure but not for the purposes of insertion of a nasogastric tube for enteral feedings.
A patient is on enteral feedings through a nasogastric tube. Which factors increase the risk of aspiration in the patient? Select all that apply. 1 Coughing 2 Diarrhea 3 Lying flat 4 Administration of prokinetic drugs 5 Gastroesophageal reflux disease
1, 3, 5 When the patient coughs, the gastric contents may aspirate into the airways. Lying flat facilitates aspiration, because gastric content can easily enter the airways due to the airways position. Gastroesophageal reflux is a condition in which the gastric contents flow back into the esophagus. This can increase the risk of aspiration. Diarrhea is unrelated to the risk of aspiration. Administration of prokinetic drugs may actually decrease the risk of aspiration by promoting gastric emptying.
Which substances are soluble fibers? Select all that apply. 1 Oats 2 Lignin 3 Barley 4 Cellulose 5 Cornmeal
1, 3, 5 Oats, barley, and cornmeal are soluble fibers, which can be dissolved in water. Lignin and cellulose are insoluble fibers, which cannot be dissolved in water and are not digestible.
Which nursing actions appropriately identify a patient prior to inserting a prescribed nasoenteric tube? Select all that apply. 1 Asking the patient to state his or her name and birth date 2 Asking the patient if he is Mr. Jones and to state his date of birth 3 Verifying the patient's name and social security number by asking a family member 4 Comparing the patient's name and medical record number on the order to the ID band 5 Asking the patient to compare the medical record number and name to the provider's order
1, 4 The nurse should verify the patient using two identifies (i.e., patient's name and birthday or name and medical record number) according to agency policy. This can be accomplished by asking the patient to state his or her name and birth date or by comparing the patient's name and medical record number on the order to the ID band placed on the patient's wrist. Asking the patient if his name is Mr. Jones elicits a yes or no answer and is not supported by the Joint Commission, because it can result in mistakes. The patient's identity should not be verified by a family member, and the patient should not be asked compare medical record number and name to the provider's order, because this requires the ability to read.
Which vitamins are fat-soluble and are stored in the adipose tissue of the body? Select all that apply. 1 Vitamin A 2 Vitamin B 3 Vitamin C 4 Vitamin D 5 Vitamin E
1, 4, 5 Vitamins are of two types, fat-soluble and water-soluble. Vitamins A, D, and E are fat-soluble and are stored in the body. These vitamins may become deficient in persons who do not include fats in their diets. Vitamins B and C are water-soluble vitamins and are found in most fruits and vegetables. These vitamins are not stored in the body.
A patient is diagnosed with complete obstruction of the bile duct due to a gallstone. The patient passes fats in the stool due to indigestion of fats. Of which vitamin deficiency is the patient at risk? Select all that apply. 1 Vitamin A 2 Vitamin B 3 Vitamin C 4 Vitamin D 5 Vitamin E 6 Vitamin K
1, 4, 5, 6 Vitamins A, D, E, and K are fat-soluble vitamins and may not be absorbed if the fats are excreted undigested. Vitamins B and C are water-soluble vitamins, and their absorption is not dependent on fats.
A pediatric nurse weighs a newborn and records the weight as 9 pounds. Considering that the baby's weight gain is adequate, what would be the approximate weight of this baby at 5 months? Record your answer using a whole number. _____ pounds
18 The birth weight of an infant usually doubles by 5 months. The baby had a birth weight of 9 pounds; therefore, at 5 months the weight would be 9 x 2 = 18 pounds.
Which nursing action prevents gastric cramping and discomfort during a nasoenteric feeding? 1 Checking the expiration date of the formula 2 Warming the patient's formula to room temperature 3 Implementing hand hygiene prior to administering formula 4 Identifying the patient using two identifiers prior to administering the formula
2 Cold formula causes gastric cramping and discomfort because the mouth and esophagus cannot warm the liquid; therefore, the nurse should warm the patient's formula to room temperature when administering a nasoenteric feeding. Checking the expiration date of the formula decreases the risk for obtaining tube feeding-borne gastrointestinal infection. Implementing hand hygiene reduces the transmission of microorganisms. Identifying the patient through the use of two identifiers ensures the correct patient will receive the procedure.
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? 1 Breast milk is the best food for my baby. 2 Cow's whole milk is a suitable alternative for breast milk. 3 Honey should not be given to the baby. 4 Corn syrup should not be given before 1 year of age
2 During the first year of a newborn baby's life, nutrition is very important because of the physiological immaturity of the digestive system. Cow's whole milk is concentrated and the infant's kidneys are not mature enough to manage it. Drinking whole cow's milk as a newborn also increases the risk of developing allergies to milk products. Cow's milk is a poor source of iron and vitamins C and E. Breast milk is the best food for the baby and should be the only food for the first 6 months. Breast milk is balanced in nutrition, does not cause allergies, is easily digestible, and is naturally at the appropriate temperature. Honey and corn syrup should not be fed to the infant during first year, because they can be sources of botulism toxin, which can be fatal in infants.
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. 1 Allow the patient to eat independently without any instructions. 2 Tell the patient where the beverages are located in relation to the plate. 3 Identify the food location on a meal plate as if it were a clock. 4 Ensure the other care providers set the meal tray and plate in the same manner. 5 Encourage the use of large-handled adaptive utensils.
2, 3, 4, 5 The patient with vision impairment should be assisted with feedings. The patient should be told where the beverage is in relation to the plate so that he or she can drink it without assistance. Identifying where the food is on the plate using a clockwise pattern helps the patient locate the food and eat without assistance. The patient may be able to eat the food without assistance if the plate is always set in the same pattern. Using large, adaptive utensils helps the patient use them effectively. The patient should not be left alone to eat if he or she is visually impaired.
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. 1 Do not wash vegetables because water-soluble vitamins can be lost. 2 Unpasteurized milk is not safe for children or adults. 3 Do not save leftovers for more than 2 days in the refrigerator. 4 Using paper towels is not good for health. 5 Wash cutting boards with hot, soapy water.
2, 3, 5 Unpasteurized milk is not safe for consumption, because it may have microorganisms in it. The milk should be boiled thoroughly before consumption. The leftover food should not be kept in the refrigerator for more than 2 days, because it may become contaminated. Cooking utensils and cutting boards should be washed with hot, soapy water to remove any microorganisms on them. Fruits and vegetables should be cleaned before eating or cooking to remove any dirt or contaminants. Paper towels are safe to wipe the hands after hand washing.
Which data should the nurse document in the medical record when providing care to a patient who is receiving enteral tube feedings? Select all that apply. 1 Goal weight 2 Patency of the tube 3 Most recent vital signs 4 Amount and type of tube feeding 5 Condition of the skin at the site of the tube
2, 4, 5 The nurse should document the patency of the patient's tube, the amount and type of tube feeding, and the condition of the patient's skin at the site of the tube. The goal weight and most recent vital signs are not included in the documentation for this patient.
Which nursing actions are appropriate when preparing the syringe for an intermittent nasoenteric feeding to a patient? Select all that apply. 1 Pinch the distal end of the tubing 2 Remove the plunger from the syringe 3 Push the formula into the tube forcefully 4 Attach the barrel of the syringe to the end of the tube 5 Fill the syringe with the measured amount of formula and elevate
2, 4, 5 When preparing the syringe for an intermittent nasoenteric feeding to a patient, the nurse should remove the plunger from the syringe, attach the barrel of the syringe to the end of the tube, and fill the syringe with the measured amount of formula and then elevate. The other actions are incorrect: The nurse should pinch the proximal, not distal, end of the tubing. The formula should be administered by gravity and not pushed into the tube forcefully.
How are active transport and passive diffusion similar? Select all that apply. 1 Both require special carriers for movement of particles. 2 Both are mechanisms for intestinal absorption of nutrients. 3 Both are processes that require energy for movement of particles. 4 Both involve engulfing large molecules of nutrients by the absorbing cell. 5 Both involve movement of particles from an area of higher concentration to one of lower concentration.
2, 5 Both active transport and passive diffusion are mechanisms for intestinal absorption of nutrients, and both move particles from an area of higher concentration to one of lower concentration. Active transport requires special carriers to move particles while passive diffusion does not require special carriers. Active transport is an energy-dependent process while passive diffusion is an energy-independent process. Pinocytosis is the mechanism which involves engulfing large molecules of nutrients by the absorbing cell when the molecule attaches to the absorbing cell membrane.
In what order does the nurse implement the following steps while administering enteral feedings via nasoenteric tube? 1. Flushing the tubing with 30 mL water 2. Placing the patient in high-Fowler's position 3. Rinsing the bag and tubing with warm water whenever feedings are interrupted 4. Advancing the rate of tube feeding gradually, as ordered by the health care provider 5. Verifying tube placement by attaching the syringe and aspirating 5 mL of gastric contents 6. Initiating feeding by removing the plunger from the syringe and attaching the barrel of syringe to the end of tube
2, 5, 1, 6, 4, 3 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.
What do proteins contain that make them different from carbohydrates? 1 Carbon 2 Oxygen 3 Nitrogen 4 Hydrogen
3 Proteins contain nitrogen whereas carbohydrates do not. Carbon, oxygen, and hydrogen are present in both carbohydrates and proteins.
Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings? 1 Obtaining an x-ray film after each feeding 2 Monitoring tube placement every 4 to 6 hours 3 Checking tube placement prior to each feeding 4 Flushing the tube with 15 mL of water to avoid clogging
3 The appropriate nursing action when providing care to a patient who is prescribed intermittent tube feedings is to check tube placement prior to each feeding. An x-ray film is often obtained to confirm placement prior to the initial tube feeding and before any feeding where the placement of the tube is questioned, but it is not necessary after each feeding. Tube placement is monitored every 4 to 6 hours for patients who are prescribed continuous, not intermittent, tube feedings. The tube is flushed with 30, not 15, mL of water to avoid clogging.
Which piece of equipment should the nurse have available to remove a small-bore nasoenteric tube for a patient whose enteral feedings have been discontinued? 1 Emesis basin 2 Tongue blade 3 Oral hygiene supplies 4 60-mL Luer-Lok catheter tip syringe
3 The nurse should have oral hygiene supplies available to remove a small-bore nasoenteric tube for a patient whose enteral feedings have been discontinued. An emesis basis, a tongue blade, and a 30-mL Luer-Lock catheter tip syringe are equipment required to insert, not remove, a small-bore nasoenteric tube.
Which nursing action is appropriate when providing care to a patient who develops diarrhea three times or more in 24 hours as a result of enteral feedings? 1 Holding the patient's current feeding 2 Rechecking the patient's gastric residual in one hour 3 Instituting skin care measures for the patient 4 Obtaining a patient prescription for pancreatic enzymes
3 The nurse should implement skin care measures for the patient who is prescribed enteral feedings and develops diarrhea to decrease the risk for perianal excoriation. Enteral feedings are held for patients who have two consecutive gastric residual volumes (GRVs) greater than 250 mL, not for a patient who develops diarrhea. The nurse would recheck the patient's gastric residual for volumes greater than 250 mL and not for a patient who develops diarrhea. Pancreatic enzymes are used to unclog enteral feeding tube, not to treat diarrhea.
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? 1 Administering a placebo 2 Creating a noise-free environment 3 Applying ice near the site of the pain 4 Performing a pain assessment frequently
3 The nursing interventions may include application of cold or heat near the affected area. Administering a placebo and creating a noise-free environment may not reduce the pain. Pain assessment should be performed frequently to evaluate the pain intensity, but this action will not relieve the pain.
A 45-year-old patient has been advanced to a low-residue diet postoperatively. What food should be avoided in the patient's diet? 1 Pastas 2 Casseroles 3 Steamed vegetables 4 Canned cooked vegetables
3 The postoperative patient needs a special diet to help the digestive system slowly adapt to a normal diet. A low-residue diet includes low-fiber foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables. Steamed vegetables should not be given, because they contain high fiber.
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? 1. Mix the aspirate in the syringe. 2. Dip the pH strip into the aspirate fluid. 3. Observe the appearance of the aspirate. 4. Compare the color on the strip to the color chart. 5. Expel a few drops of the aspirate into a clean medicine cup.
3, 1, 5, 2, 4 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.
Upon assessing a patient, the nurse suspects anorexia nervosa. What behavioral finding may have led the nurse to this suspicion? 1 Frequent self-induced vomiting 2 Recurrent episodes of binge eating 3 Frequent use of laxatives or diuretics 4 Fear of becoming fat despite being significantly underweight
4 Fear of becoming fat despite being significantly underweight is indicative of anorexia nervosa. A patient with anorexia nervosa refuses to eat in order to stay at or below a minimal normal weight for his or her age and height. Frequent self-induced vomiting, recurrent episodes of binge eating, and frequent use of laxatives or diuretics are more characteristic of bulimia nervosa than of anorexia nervosa.
While caring for a patient on fentanyl infusion therapy, the nurse monitors vital signs and pulse oximetry every 1 to 2 hours for the first 24 hours. What is the rationale for this nursing action? 1 To prevent the risk of infection 2 To ensure unimpeded flow of infusion 3 To ensure the patency of intravenous line 4 To prevent the risk of respiratory depression
4 Fentanyl is a synthetic opioid that is used to reduce pain perception. While infusing opioids, the nurse has to monitor the patient's level of sedation, vital signs, and pulse oximetry every 1 to 2 hours for the first 12 hours. This helps to reduce the risk of excess sedation that results in respiratory depression. Ensuring aseptic environment during infusion helps to prevent the risk of infection. Positioning the patient in a comfortable angle helps to ensure unimpeded flow of infusion. Protecting the venipuncture or central line site helps to maintain patency of the intravenous line.
Which factor contributes to peptic ulcer formation? 1 Spicy foods 2 Decreased gastrin production 3 Increased bicarbonate retention 4 Helicobacter pylori infection
4 Helicobacter pylori is a bacterium that promotes peptic ulcers, although the mechanism is not firmly established. It may cause enzymatic degradation of the protective mucus layer and promote elaboration of a cytotoxin that injures mucosal cells. It may also facilitate infiltration of neutrophils and other inflammatory cells in response to the bacterium's presence. Spicy foods do not contribute to ulcer formation; however, certain seasonings such as hot chili pepper, chili powder, and black pepper may increase stomach acidity. Reduced gastrin (a hormone that stimulates gastric acid secretion) production is not a contributing factor to ulcer formation. Bicarbonate, an indicator of the alkali retention, does not contribute to ulcer formation, a condition in which high acidity is common.
Which nursing action is appropriate prior to administering a nasoenteric feeding? 1 Monitoring the platelet count 2 Drawing a red blood cell count 3 Obtaining an arterial blood gas 4 Assessing capillary blood glucose
4 Prior to implementing a nasogastric feeding, the nurse should monitor laboratory values, including electrolytes and capillary blood glucose levels. These values provide a baseline to measure the patient's response to enteral nutrition. It is not necessary for the nurse to monitor the platelet or red blood cells counts or to obtain an arterial blood gas prior to implementing a nasoenteric feeding for a patient.
Which nursing action is appropriate when providing care to a patient whose enteral feeding tube is clogged? 1 Conferring with the patient's dietician 2 Rechecking the patient's tube in 1 hour 3 Instituting skin care measures for the patient 4 Using pancreatic enzymes
4 The appropriate nursing action for a patient whose enteral feeding tube is clogged is to use pancreatic enzymes to unclog the tube. A dietician should be consulted if the patient develops diarrhea three times in a 24-hour period but not for a patient who has a clogged feeding tube. Rechecking the tube in an hour is an appropriate intervention for a patient who has a large gastric residual volume (GRV) but not for a patient whose feeding tube is clogged. Instituting skin care measures is more appropriate for a patient experiencing diarrhea, not for a patient whose enteral feeding tube is clogged.
Which nursing action is appropriate when observing a patient for dysphagia during an aspiration risk assessment? 1 Eliciting a gag reflex 2 Measuring the patient's oxygen saturation 3 Performing a nutrition screening on the patient 4 Observing the patient eat various consistencies of food
4 The appropriate nursing action when observing a patient for dysphagia during an aspiration risk assessment is to watch the patient eat various consistencies of foods and liquids. This helps the nurse detect abnormal eating patterns such as frequent clearing of the throat or prolonged feeding time. While eliciting a gag reflex, measuring the oxygen saturation, and performing a nutritional screening are all appropriate nursing actions during an aspiration risk assessment, these actions are not performed when observing a patient for dysphagia during an aspiration risk assessment.
The nurse is caring for a patient for whom nasogastric tube feedings have been ordered. What amount of gastric residual volume (GRV) indicates delayed gastric emptying? 1 250 mL or more on two consecutive assessments 30 minutes apart 2 150 mL or more in on two consecutive assessments 1 hour apart 3 More than 350 mL in a single gastric reserve volume measurement 4 More than 500 mL in a single gastric reserve volume measurement
4 The stretch reflex allows the food to move from the stomach into the duodenum, and food or fluids are not allowed into the esophagus when the lower esophageal sphincter is normal. If the reserve is greater than normal, there is a risk of regurgitation and aspiration of gastric contents into the lungs. If the gastric reserve volume of the stomach is 500 mL in a single assessment, it indicates delayed gastric emptying. A gastric residual volume of 250 mL on two consecutive assessments 30 minutes apart indicates that the feedings are tolerated well. A gastric residual volume of 150 mL on two consecutive assessments 30 minutes apart also indicates tolerance towards enteral feedings. More than 350 mL in a single gastric reserve volume measurement indicates that the feedings are being accepted well.
A nurse must administer enteral feeding via nasoenteric tube to a patient. In what order should the nurse perform the procedure? 1. Identify the patient using two identifiers according to agency policy. 2. Attach the syringe, and aspirate 5 mL of gastric contents. 3. Monitor the intake and output every eight hours, and calculate daily totals every 24 hours. 4. Obtain baseline weight and laboratory values to assess the nutritional status of the patient.
4, 1, 2, 3 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.
The nurse is checking feeding tube placement. Place the steps in the proper sequence. 1. Draw 5 mL to 10 mL gastric aspirate into syringe. 2. Flush tube with 30 mL air. 3. Mix aspirate in syringe and place in medicine cup. 4. Perform hand hygiene and put on clean gloves. 5. Observe color of gastric aspirate. 6. Compare strip with color chart from manufacturer. 7. Dip pH strip into gastric aspirate.
4, 2, 1, 5, 3, 7, 6 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.
A community nurse is assessing the health of all the members in a family. Which signs and symptoms indicate a deficiency of calcium? Select all that apply. 1 Pallor of conjunctiva and skin 2 Enlargement of thyroid gland 3 Bleeding gums 4 Stunted growth in children 5 Fragile bones in older women
4, 5 Calcium is required for healthy bone growth and bone density. Children with a calcium deficiency may appear short for their age. Even after attaining full growth of bones, calcium is required to maintain the density of bone. A calcium deficiency may make the bones fragile. An iron deficiency leads to anemia, which may cause the skin and the conjunctiva to appear pale. Enlargement of the thyroid gland is seen in goiter caused by iodine deficiency. A deficiency of vitamin C may result in bleeding gums.
