N411: GI and Nutrition Test Bank Questions
The nurse is caring for a patient with liver disease. When assessing the patient's laboratory values, the nurse should
B: assess the total bilirubin
Malnutrition contributes to infection risk by
B: impaired immune fx Malnutrition impairs immune function.
The nurse identifies which patient at greatest risk for malabsorption of protein?
B: the patient with ileitis The ileum is where protein is broken down and absorbed; the patient with ileitis would be at greatest risk for protein malabsorption.
The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should answer:
C: "injury to certain cells in the pancreas causes it to digest (eat itself, causing pain) The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.
Patients experiencing severe physiological stress increase their nutritional requirements to:
C: 35 kcal/kg/day Severely stressed individuals require 35 kcal/kg/day; 50 kcal/kg/day exceeds caloric needs. A total of 20 kcal/kg/day is less than normal caloric requirements. A total of 30 kcal/kg/day is the caloric requirement for a moderately stressed individual.
The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss?
C: HR 125 BPM As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume.
The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. The nurse should
C: cut all three lumens and remove the tube Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible life-threatening complications that need to be assessed. Esophageal rupture may also occur and is characterized by the abrupt onset of severe pain. In the event of any of these life-threatening emergencies, all three lumens are cut and the entire tube is removed. For this reason, scissors are kept at the patient's bedside at all times. Endotracheal intubation is strongly recommended to protect the airway.
The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse
D: administers pain medication on a routine schedule Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the form of a patient-controlled analgesia (PCA) pump. In the case in which a PCA pump is not ordered, pain medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.
A patient is receiving enteral tube feedings and has developed drug-nutrient interactions. The nurse recognizes which drug as having the potential for causing drug-nutrient reactions?
D: phenytoin Bioavailability of phenytoin is reduced when administered with enteral feedings. The other drugs do not have significant drug-nutrient interactions.
CRITICAL THINKING Q: Which team members would the nurse consult to assist with the nutritional support of critically ill patients?
Several members of the multiprofessional team may need to be consulted. • Orders will be written by the intensivist; however, the clinical dietitian is usually involved in conducting a nutritional assessment and in making recommendations. • A clinical pharmacist with expertise in parenteral nutrition is often consulted to order TPN. • A speech-language pathologist may be consulted to evaluate swallowing and ability to tolerate oral feeding.
The correct order of actions for a patient starting enteral nutrition with a feeding tube is: _______________, _______________, _______________, _______________, _______________.
insert feeding tube, obtain chest radiograph, flush tube to verify patency, initiate tube feeding, assess residuals Initially the feeding tube will be inserted and final placement verified via chest radiograph. The next step is to flush the feeding tube and start the tube feedings. Residuals are checked every 4 hours.
In addition to residual stomach volume, what other evidence suggests feeding intolerance?
A: abdominal distension Abdominal distension is expected if the feedings are not being absorbed. Tympany occurs along with distension.
The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and tetracycline but is not responding. The nurse expects that
A: bismuth will be added to the current triple therapy Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth, metronidazole, and a tetracycline. A 10-day course of levofloxacin may also be administered as a second-line therapy for H. pylori infections.
Approximately 5 days after starting tube feedings, a patient develops extreme diarrhea. A stool specimen is collected to check for which possible cause?
A: clostridium difficile Patients receiving enteral nutrition who develop diarrhea are evaluated for antibiotic- associated causes, including Clostridium difficile.
The nurse is caring for a patient with a heart rate of 140. The provider orders parasympathetic medications to slow down the HR. With this type of medication, the nurse should
B: observe for diarrhea Functions of the GI system are influenced by neural and hormonal factors. Parasympathetic cholinergic fibers, or drugs that mimic parasympathetic effects, stimulate GI secretion and motility.
The patient is diagnosed with hepatitis. In caring for this patient, the nurse should
B: provide rest, nutrition, and antiemetics if needed No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.
Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse
C: assess the patient for epigastric discomfort Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment.
The nurse is assessing a patient admitted with pancreatitis. In doing so, the nurse
C: assesses symptoms that could indicate involvement of the stomach Because the pancreas lies retroperitoneally, it cannot be palpated; this characteristic explains why diseases of the pancreas can cause pain that radiates to the back. In addition, a well-developed pancreatic capsule does not exist, and this may explain why inflammatory processes of the pancreas can spread freely and affect the surrounding organs (stomach and duodenum).
A patient is being fed through a nasogastric tube placed in his stomach. The nurse would carry out which intervention to minimize aspiration risk?
C: elevated HOB 30 degrees The head of the bed should be kept elevated at least 30 degrees if possible during tube feedings to minimize reflux. Blue dye should not be used. Neither continuous feedings nor checking for residual will minimize aspiration.
The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse
C: has the patient take a deep breath The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration. Pulsations, if they are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and hydration status, not masses. Abdominal distension, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity.
The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the lab work a few hours later. The new hemoglobin and hematocrit would be expected to be
C: hemoglobin 10.5 g/dL and hematocrit 32% One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%, but this effect is influenced by the patient's intravascular volume status and whether the patient is actively bleeding.
A patient has been admitted to the critical care unit after a stroke. After "failing" a swallow study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step?
C: obtain a chest radiograph Correct placement must be verified by radiograph before use of the tube for either feeding or administering medications. There is no reason to cap the tube and wait; once placement is verified, the tube can be used.
The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must
D: deflate the esophageal balloon before the gastric balloon It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached to a helmet or to the foot of the bed (not the side rail). Proper amounts of traction are essential because too little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.
A patient, who has a tube feeding, requires a chest x-ray study for evaluation of a cough. To reduce the risk of aspiration, the nurse:
D: stops feedings 10-15 minutes before placing flat to obtain the radiograph
The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer
A: H2-histamine receptor blockers Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid. Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine and therefore hydrochloric acid stimulation. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia but has no effect on ulcer formation. Gastrin is a hormone that stimulates acid. The vagus nerve helps digestion; however, vagal stimulation is not a treatment for peptic ulcer disease.
The nurse is caring for a critically ill patient with end-stage liver disease. The nurse knows that the patient is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a hyperdynamic status?
A: JVD Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distension, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases, and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.
The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that
A: Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal anti-inflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair.
Calorie-dense feedings: (Select all that apply.)
A: are most useful in HF and liver disease C: contain 2 kcal/mL and 70 g protein/L Calorie-dense feedings are used when volume should be minimized and protein requirements are high, such as in heart failure or liver disease. They contain 2 kcal/mL and 70 g protein/L. Specific formulas, such as Oxepa, are available for lung disease.
The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the SNS, vitamin B12, and an H2 blocker. The nurse should do which of the following?
A: assess for signs of peptic ulcer Secretion of mucus by Brunner's glands is inhibited by sympathetic stimulation, which leaves the duodenum unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract is the site for more than 50% of peptic ulcers. Sympathetic stimulation produces a scant output of thick saliva. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia. However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium, potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk for fluid and electrolyte imbalances and acid-base disturbances. However, nothing indicates that the patient is vomiting or has GI suction.
Which statements about total parenteral nutrition are correct? (Select all that apply.)
A: assessing fluid volume status and preventing infection are important nursing considerations B: fingerstick glucose levels are assessed every 6H and PRN D: total parenteral nutrition with added lipids provides adequate levels of protein, carbs, and fats E: soy-based lipids should not be given during the first week of a critical illness All are correct except administration via a feeding tube and pump. A tube and pump are used to deliver enteral nutrition.
A patient with severe burns had a dietitian consultation for nutritional support. The patient weighs 145 pounds. What recommendations by the dietitian does the nurse anticipate initiating? (Select all that apply.)
A: at least 2307 kcal/day B: juven formula The severely stressed patient requires around 35 kcal/kg/day. This patient weighs 145 pounds, which is 65.9 kg. So this patient needs at least 2307 kcal/day. Juven is an appropriate formula; 2 cal HN is used for patients with heart and/or liver disease and Perative is used for patients with impaired GI function.
The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that the pain has become extreme. The nurse notes that the patient's abdomen is rigid. The nurse should
A: call the provider immediately Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine blockers may or may not be indicated, depending on the cause of the upper GI bleeding. Mortality rates for patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the time of surgery; therefore, it is essential that the provider be called immediately.
The liver detoxifies the blood by
A: converting fat-soluble compounds to water-soluble compounds Drugs, hormones, and other toxic substances are metabolized by the liver into inactive forms for excretion. This process is usually accomplished by conversion of the fat-soluble compounds to water-soluble compounds. They can then be excreted via the bile or the urine.
Infection by Helicobacter pylori bacteria is a major cause of
A: duodenal ulcers Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that develop as a result of burn injury are often called Curling's ulcers. Stress ulcers associated with severe head trauma or brain surgery are called Cushing's ulcers.
The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse
A: evaluate renal fx studies daily Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to the kidneys (not liver) and therefore cannot be given to patients with renal failure. Daily renal function studies are monitored when neomycin is administered. Guaiac tests are used to detect occult bleeding.
Pain control is a nursing priority in patients with acute pancreatitis because pain
A: increases pancreatic secretions Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patient's metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distension of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.
Nursing priorities for the management of acute pancreatitis include: (Select all that apply.)
A: managing respiratory dysfunction B: assessing and maintaining electrolyte balance E: utilizing supportive therapies aimed at decreasing gastric release Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.
The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should
A: monitor the patient's BP and evaluate for signs of dehydration In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity. Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of acute pancreatitis. The IV solutions ordered for fluid resuscitation are usually colloids or lactated Ringer's solution; however, fresh frozen plasma and albumin may also be used. IV fluid administration with crystalloids at 500 mL/hr is at times required to maintain hemodynamic status. Often, vigorous IV fluid replacement at 250 to 300mL/hr continues for the first 48 hours or a volume adequate to maintain a urine output of greater than or equal to 0.5 mL/kg body weight per hour. Fluid replacement helps to maintain perfusion to the pancreas and kidneys, reducing the potential for complications.
The patient is admitted with generalized fatigue and low hemoglobin and hematocrit levels. The patient denies vomiting and states that the last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to
A: obtain a stool sample for guaiac testing GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac). Stool and nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black, foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting or drainage from a nasogastric tube that yields blood or coffee-ground-like material is associated with upper GI bleeding. However, blood or coffee-ground-like contents may not be present if bleeding has ceased or if it arises beyond a closed pylorus.
The nurse is caring for a patient with severe pancreatitis who is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and
A: places the patient on seizure precautions Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low, and replacement of calcium is expected.
The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to
A: rule out massive upper GI bleeding Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool with a chemical reagent (guaiac).
When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.)
A: severity of blood loss B: hemodynamic stability E: necessity for fluid resuscitation Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.
Which of the following statements is true about insulin and parenteral nutrition? (Select all that apply.)
A: the amount of parenteral insulin is adjusted based on the previous 24H laboratory values B: insulin may be added to parenteral nutrition solution C: subcutaneous insulin is used on a sliding scale during TPN Hyperglycemia is common when receiving parenteral nutrition; insulin may be administered on a sliding scale for glucose control and/or added to the parenteral solution. The amount of insulin added to the parenteral solution is calculated based on the previous 24-hour laboratory values. Hypoglycemia can result from continuing the insulin after the parenteral nutrition is discontinued.
After gastric bypass surgery, the patient is getting vitamin B12 injections. The patient asks about the purpose of this vitamin. The nurse explains that
A: vitamin B12 us needed for the formation of RBCs Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach. Vitamin B12 is essential in the formation of red blood cells. A deficiency of B12 does lead to anemia, but this answer is not as specific as stating the relationship of B12 to red blood cells, so it is not as informative. Vitamins A and C are more essential for wound healing. Obese people may or may not be deficient in this vitamin.
The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.)
B: PPIs C: anticholinergic drugs D: antacids Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.
The patient is admitted with the diagnosis of GI bleeding. The patient's heart rate is 140 beats per minute, and the blood pressure is 84/44 mm Hg. These values may indicate:
B: approximately 25% loss of total blood volume Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.
Which interventions are critical during intravenous lipid administration? (Select all that apply.)
B: change the tubing Q24H D: monitor triglyceride levels periodically Lipids are very good media for bacterial growth; lipid tubing should be changed every 24 hours. Triglyceride levels must be monitored until stable when administering lipids. Glucose is monitored during treatment with parenteral nutrition, which contains a high level of glucose. Medications are not administered through the IV lines containing lipids or parenteral nutrition. Elevating the head of the bed is important for enteral (tube) feedings to prevent aspiration.
The patient is admitted for GI bleeding, but the source is unknown. Before ordering endoscopy, the provider orders octreotide to be given intravenously. The purpose of this medication is to
B: decrease splanchnic blood flow and portal pressure Octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow, reduce portal pressure, and have minimal adverse effects Octreotide does not increase portal pressure, vasodilate the splanchnic arteriolar bed, or increase blood flow in the liver's collateral circulation.
Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.)
B: dilated vessels C: tortuous vessels D: constricted vessels Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate infection, abscess, or tumor.
Risks of total parenteral nutrition include: (Select all that apply.)
B: elevated blood sugar C: infection at catheter site D: volume overload Diarrhea and aspiration are more common with enteral tube feedings; the other risks are common with total parenteral nutrition.
A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate?
B: fiber-added formula Added fiber helps to control blood glucose and reduce hyperlipidemia.
The best nursing approach to prevent feeding tube obstruction is to
B: flush the tube every 4H with 20-30 mL of tap water Flushing the tubing every 4 hours helps prevent obstruction. Diluting tube feedings can cause water intoxication. Stylets are never used to clear a tube, and the smallest bore possible should be used for best tolerance.
The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient
B: has a 15% chance of dying Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient's chance of significant morbidity and mortality. In Ranson's research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.
The nurse is to assist the provider in performing bedside endoscopy on a patient. To prevent respiratory complications, the nurse places the patient
B: in a left lateral reverse Trendelenburg position Because endoscopy is performed at the patient's bedside, the nurse assists with procedures and monitors for untoward effects. Maintenance of airway and breathing during endoscopic procedures is of major concern. Placement of the patient in a left lateral reverse Trendelenburg position helps to prevent respiratory complications.
A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care?
B: infuse abx through the IV line Medications should not be infused through the IV line infusing parenteral nutrition. The other actions are correct.
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.)
B: malnutrition C: ascites E: disseminated intravascular coagulation (DIC) Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop.
The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurse's first action should be to
B: position the patient in a semi-Fowler's position Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowler's position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowler's position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.
The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to
B: provide therapies that will innervate the autonomic nervous system The second layer of the gut wall, the submucosa, is composed of connective tissue, blood vessels, and nerve fibers. Beneath the mucosa, submucosa, and muscular layer are various nerve plexuses that are innervated by the autonomic nervous system. disturbances in these neurons in a given segment of the GI tract cause a lack of motility. Therapies innervating the autonomic nervous system are thus appropriate. The muscular layer is the major layer of the wall. The serosa is the outermost layer
A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy?
B: sepsis and F/E imbalances Because of the high dextrose concentration, including the fluid and electrolyte content, the patient is placed at high risk for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a potential complication of enteral feedings; sepsis is a potential complication of parenteral nutrition. Fluid overload is possible but unlikely and is not a major complication of parenteral nutrition. Hyperglycemia is more of a concern than hypoglycemia with parenteral nutrition; however, renal insufficiency is not related to parenteral nutrition.
The nurse is assessing the patient and notices that the oral cavity is only slightly moist and contains a scant amount of thick saliva even though the patient's fluid intake has been sufficient. The nurses realize that the condition of the patient's mouth is probably caused by
B: sympathetic nerve stimulation Saliva is the major secretion of the oropharynx and is produced by three pairs of salivary glands: submaxillary, sublingual, and parotid. Stimuli such as sight, smell, thoughts, and taste of food stimulate salivary gland secretion. Parasympathetic stimulation promotes a copious secretion of watery saliva. Conversely, sympathetic stimulation produces a scant output of thick saliva. The normal daily secretion of saliva is 1200 mL.
Lactulose is considered the first-line treatment for hepatic encephalopathy and works by
B: trapping ammonia in the bowel for excretion Lactulose is considered the first-line treatment for hepatic encephalopathy. Lactulose creates an acidic environment in the bowel that causes the ammonia to leave the bloodstream and enter the colon. Ammonia is trapped in the bowel. Lactulose also has a laxative effect that allows for elimination of the ammonia. Lactulose is given orally or via a rectal enema.
CRITICAL THINKING Q: When would hematochezia occur secondary to upper GI bleeding? Why are bowel sounds often hyperactive in GI bleeding?
Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding, but can be seen when upper GI bleeding is massive (>1000 mL). Bowel sounds may be hyperactive as active bleeding is passed quickly through the GI tract.
When assessing the patient's bowel sounds, the nurse
C: listens to bowel sounds before palpation Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract. Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is performed before auscultation is begun. A supine position with the patient's arms at the sides or folded at the chest is usually recommended. Placing a pillow under the patient's knees also helps to relax the abdominal wall.
In evaluating a patient's nutrition, the nurse would monitor which blood test as the most sensitive indicator of protein synthesis and catabolism?
C: prealbumin Prealbumin is the most sensitive indicator of protein synthesis and catabolism.
The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that
C: pseudocysts may resolve spontaneously, so surgery may be delayed Surgery may be indicated for pseudocysts; however, it is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed. Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peritonitis.
The liver plays a major role in homeostasis by
C: removing active clotting factors from the circulation The liver synthesizes fibrinogen (factor I); prothrombin (factor II); and factors VII, IX, and X. Vitamin K is essential for the synthesis of other clotting factors. The liver also removes active clotting factors from the circulation and therefore prevents clotting in the macrovascular and microvascular.
A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. What action by the nurse takes priority?
C: stop the tube feeding Nausea and vomiting are signs of tube feeding intolerance. The nurse should first stop the feeding. Then the nurse can assess for other signs of intolerance and aspiration. After a complete assessment, the nurse would notify the provider.
The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that
C: the hematocrit value does not change substantially during the first few hours The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated by fluids and blood products that are administered during the resuscitation period.
An important nutritional consideration in the elderly population is
C: the potential for drug-nutrient interaction related to polypharmacy Patients taking multiple medications have a greater potential for drug-nutrient interactions; older adults may be taking multiple medications.
CRITICAL THINKING Q: What symptoms will you see if the patient is developing hypovolemic shock secondary to GI bleeding?
Changes in blood pressure and heart rate depend on the amount of blood loss, the suddenness of the blood loss, and the degree of cardiac and vascular compensation. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume.
A patient is receiving enteral feedings and reports fullness and abdominal discomfort. What action by the nurse is best?
D: assess the patient's gastric residual The patient may not be tolerating the tube feeding. The nurse should assess the gastric residual and hold the feeding if it is greater than 500 mL. The other actions are not warranted; the nurse needs further information before proceeding.
The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure
D: decrease rebleeding Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites occurs after all these procedures, and careful assessments and interventions are required in the care of this patient population.
The patient is admitted with acute pancreatitis. The nurse should
D: evaluate C-reactive protein as a gauge of severity The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease, gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed, these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. C-reactive protein increases within 48 hours and is a marker of severity.
Select the physiological reasoning behind enteral therapy as the preferred source of nutritional therapy.
D: gut mucosa is preserved Enteral feedings prevent bacterial overgrowth and potential bacterial translocation from the gastrointestinal tract and preserve the gut mucosa.
Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that
D: immediate oral feeding in patients with mild pancreatitis may help recovery Nasogastric suction and "nothing by mouth" status were classic treatments for patients with acute pancreatitis to suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally, secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum; therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric distension, and a decreased level of consciousness to prevent complications resulting from pulmonary aspiration. However, trends in nutritional management are changing. NPO status and NG suction are not used as much, especially for mild cased. Early nutritional support may be ordered to prevent atrophy of gut lymphoid tissue, prevent bacterial overgrowth in the intestine, and increase intestinal permeability. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery. Early enteral nutrition appears effective and safe.
In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that
D: increasing intensity of pain is always significant Pain assessment is challenging. Pain receptors in the abdomen are less likely to be localized and are mediated by common sensory structures projected to the skin. Therefore, distinguishing the pain of a peptic ulcer or cholecystitis from that of a myocardial infarction is often difficult. Abdominal pain often is caused by engorged mucosa, pressure in the mucosa, distension, or spasm. Visceral pain is likely to cause pallor, perspiration, bradycardia, nausea and vomiting, weakness, and hypotension. Increasing intensity of pain, especially after surgery or other intervention, is always significant and usually signifies complicating factors, such as inflammation, gastric distension, hemorrhage into tissue or the peritoneal space, or peritonitis.
The patient is ordered to have large-volume gastric lavage. The nurse will most likely need to
D: insert a large bore NGT Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction. If lavage is ordered, 1 to 2 liters of room-temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric tube may be left in or removed.
The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitor (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely to be secondary to
D: ischemia associated with sepsis A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Ischemia is the prior etiology associated with stress ulcer formation. Ischemic ulcers develop within hours of an event such as hemorrhage, multisystem trauma, severe burns, heart failure, or sepsis. The shock, anoxia, and sympathetic responses decrease mucosal blood flow, leading to ischemia. The secretion of acid is important in the pathogenesis of ulcer disease. Acetylcholine (a neurotransmitter), gastrin (a hormone), and secretin (a hormone) stimulate the chief cells, which stimulate acid secretion. Parietal cell mass in people with peptic ulcer disease is 1.5 to 2 times greater than in persons without disease. Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers.
When assessing bowel sounds, the nurse
D: listens for 5 minutes before noting "absent bowel sounds" Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made.
The patient is to start parenteral nutrition. The nurse knows to prepare which site for catheter insertion?
D: subclavian vein Total parenteral nutrition is administered through a central intravenous line, such as the subclavian vein. Arteries are never used. The femoral site is avoided. The basilic vein is not a central site.
A patient is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement?
D: to prevent aspiration of feedings Patients who are on a ventilator and who are receiving tube feedings are at a high risk for aspiration and ventilator-associated pneumonia. Assessment of tube placement will neither determine presence of paralytic ileus nor maintain patency. Assessment of tube placement is performed to minimize aspiration risk, not skin breakdown on the nose.
A critically ill patient has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this patient to receive?
D: vitamin A Vitamin A is vital for wound healing. Arginine is also important in wound healing but is more important for trauma and septic patients, as are omega-3 fatty acids. Branched-chain amino acids are very important for stressed patients who have liver dysfunction or ARDS.
The patient is being admitted to the hospital. At home, the patient takes an OTC supplement of vitamin D and is concerned bc the doctor did not order the vitamin D to be given in the hospital. The nurse explains that
D: vitamin D is stored in the liver with a 10 month supply to prevent deficiency The liver plays a central role in the storage, synthesis, and transport of various vitamins and minerals. It functions as a storage depot principally for vitamins A, D, and B12, where up to 3-, 10-, and 12-month supplies, respectively, of these nutrients are stored to prevent deficiency states. The kidneys do not produce vitamin D. Over-the-counter supplements are ordered, depending on the patient's status.
Objective data designating that the nutrition goals are not being met include
D: weight loss, elevated glucose, and dehydration When nutritional goals are not being met, the patient experiences weight loss, elevated glucose levels, and either overhydration or dehydration.
Which statement is true about normal function of the gastrointestinal (GI) tract?
D: without nutritional stimulation, mucosal villi atrophy Mucosal villi replenish every 3 to 4 days; without nutritional stimulation, they atrophy. The other statements are false.
CRITICAL THINKING Q: What are your priorities for GI bleeding, regardless of etiology?
Patients who are hemodynamically unstable need to have immediate venous access (using large-bore intravenous [IV] catheters), and administration of fluid is started. For the restoration of vascular volume, fluids are infused as rapidly as the patient's cardiovascular status allows and until the patient's vital signs return to baseline. Patients who continue to bleed, or who have an excessively low Hct value (<25%) and have clinical symptoms, are resuscitated with blood and blood products based on laboratory data and clinical examination. Blood is transfused to improve oxygenation (by increasing the number of RBCs) or to improve coagulation (by replacing platelets and plasma).
