Iggy 55
When working with older adults to promote good nutrition, what action(s) by the nurse is(are) most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures (if worn) for appropriate fit. c. Ensure that the client has glasses on or contacts in when eating. d. Provide salty or highly spicy foods that the client can taste. e. Serve high-calorie, high-protein snacks one to two times a day
a. Allow uninterrupted time for eating. b. Assess dentures (if worn) for appropriate fit. c. Ensure that the client has glasses on or contacts in when eating. e. Serve high-calorie, high-protein snacks one to two times a day Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses or contacts, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty or spicy snacks are not recommended because all adults should limit sodium in their diets and spicy foods may not be tolerated
The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin
a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin
The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.
a. Ask the client if the weight loss was intentional. This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? a. Assess the 24-hour intake and output. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Increase the infusion rate of the TPN
a. Assess the 24-hour intake and output. This client has clinical indicators of dehydration, so the nurse calculates the patient's 24-hour intake, output, and fluid balance. This information is then reported to the health care provider. The client's oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client's dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate would make the problem worse, and is not done as an independent action for clients receiving TPN.
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What approach by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client that lifestyle changes are always hard
a. Assess the client's coping and support systems. The nurse would assess this patient's coping styles and support systems to best provide holistic care. The other options do not address the patient's distress.
The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? a. Check the skin around the tube insertion site. b. Weigh the client every shift with the same scale. c. Draw blood to assess albumin every shift. d. Irrigate the tube at least once a day
a. Check the skin around the tube insertion site. The most important assessment would be to observe the skin around the tube for irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage and moisture which can lead to excoriation or other type of skin breakdown. For a client who is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive indicator of over nutritional health. The G-tube is not routinely irrigated
A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time? a. Listen to the client's bowel sounds. b. Call the Rapid Response Team. c. Take the client's vital signs. d. Contact the primary health care provider
c. Take the client's vital signs. The client may be experiencing either bleeding or anastomosis leak(s). Clients having these complications have severe abdominal, back, or shoulder pain, tachycardia, and hypotension
The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2. What does this value indicate to the nurse? a. The client has a healthy weight. b. The client is underweight. c. The client is obese. d. The client is overweight.
c. The client is obese. A BMI of over 30 indicates that the client is obese
The nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages
a. Cultural food preferences c. Increased need for nutrition d. Need for NPO status e. Staff shortages Many factors increase the hospitalized client's risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill patients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume that the snacks are leading to undernutrition
A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for the nurse to provide? a. "Increase the fiber and water in your diet to prevent diarrhea." b. "Report any suicidal thoughts to your primary health care provider" c. "Report dry mouth and decreased sweating." d. "Do not take antibiotics or nay other anti-infective drugs."
b. "Report any suicidal thoughts to your primary health care provider" Lorcaserin can cause suicidal thoughts which needs to be reported to the client's primary health care provider. This drug can also cause dry mouth but not decreased sweating. Loose stools are most common with orlistat. Increasing fiber and water would help to prevent constipation, not diarrhea
A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes
b. Beginning venous thromboembolism prophylaxis Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first
A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? a. Client with an albumin of 3.5 g/dL b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) c. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) d. Client with a prealbumin of 28 mg/dL
b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.
A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.
b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. e. Try to flush the tube with 30 mL of water and gentle pressure. If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula
The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? a. Intermittent diarrhea b. Cholecystitis c. Aspiration pneumonia d. Peptic ulcer disease
c. Aspiration pneumonia Aspiration pneumonia is one of the most common complications in older adults who have enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased. Intermittent diarrhea may also occur, but that is not potentially life threatening if the client does not become dehydrated
A client just returned to the surgical unit after an open traditional gastric bypass. What action by the nurse is the priority? a. Assess the patient's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump
c. Ensure an adequate airway. All actions are appropriate care measures for this patient; however, airway is always the priority. Bariatric patients tend to have short, thick necks that complicate airway management
A nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the nurse include in the directions to the AP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn't get spoiled. b. Assess the patient's mouth while providing premeal oral care. c. Ensure that warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.
c. Ensure that warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed. The AP should make sure that food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The AP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse
A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the patient's gastric residual. c. Hold the feeding until the vomiting subsides. d. Reduce the rate of the tube feeding by half.
c. Hold the feeding until the vomiting subsides. The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary health care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.
A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by the nurse is the priority? a. Auscultate lung sounds after each feeding. b. Weigh the client daily on the same scale. c. Check tube placement every 8 hours. d. Check tube placement before each feeding.
d. Check tube placement before each feeding. For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met, but it is not the priority
The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? a. Assess for carbon dioxide using capnometry. b. Perform pH testing of gastric fluid. c. Auscultate over the epigastric area. d. Request an x-ray before starting the feeding.
d. Request an x-ray before starting the feeding. The most reliable assessment to determine correct feeding tube placement in to have an x-ray to visualize where the tip of the tube is located
