NURSING CONCEPTS NUTRITION AND BOWEL ELIMINATION
A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 lb. What would the nurse document as his BMI?
52.4. BMI ={ WEIGHT / INCHES SQUARED } * 703
A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James?
A body mass index (BMI) between 25 and 29.9 is considered overweight.
The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?
A chronic deficiency of iodine can lead to endemic goiter. The major initial symptom is an enlarged thyroid gland.
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?
A client who has a fever would have an increased BMR. The energy needs of the body are increased due to the client's fever. The BMR is decreased in an older adult client, a client who is fasting, and a client who is asleep.
The nurse is providing care for a client who is ordered nothing by mouth (n.p.o.). What is an important nursing intervention?
A client who is n.p.o. cannot have any food or fluids; good oral hygiene is important for comfort and to relieve a dry mouth. Keeping the water pitcher at the bedside and filling out a menu are contraindicated for a client who is n.p.o. The nurse should encouraging the family to eat elsewhere but not at the bedside of a client who is n.p.o.
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?
A client with a BMI below 18.5 should be considered underweight. A client with a BMI of 18.5 to 24.9 is considered to be at a healthy weight. A client with a BMI of 25 to 29.9 is considered overweight; a client with a BMI of 30 or greater indicates obesity. A BMI greater than 40 is considered extreme obesity.
A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?
A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet. Reference:
A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?
A healthy stoma is dark pink to red and moist. Redness, as well as moisture, is normal to the stoma. Pallor may suggest anemia and a dark appearance may indicate ischemia.
An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:
A negative nitrogen balance exists when excretion of nitrogen exceeds the intake.
A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube?
Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement.
A client has had abdominal surgery and 72 hours later develops abdominal distention and absence of bowel sounds with pain. The nurse suspects the client has: You Selected:
An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention.
A nurse is administering a prescribed dose of IV fluid to a young client with anorexia at the health care facility. When reviewing the client's medical record, which condition would the nurse identify as a possible cause for the client's anorexia?
Anorexia can be caused due to depression, gastrointestinal (GI) dysfunction, infections, illnesses, malignancies, and side effects of many medications. Anorexia results in decreased food intake. Motion sickness, general anesthesia, and inner ear infection may cause vomiting and nausea, but not anorexia.
Which medical diagnosis is most likely to necessitate testing for fecal occult blood?
Any health problem that involves bleeding of the GI tract, such as peptic ulcer disease, may require fecal occult blood testing (FOBT). Constipation does not indicate a need for FOBT unless hardened stool is suspected of causing GI trauma. Similarly, GERD may require FOBT only if esophageal bleeding is suspected. Liver disease is not a common indication for FOBT.
When planning interventions in the immediate hours after birth the nurse recognizes the need to provide an injection of which vitamin (to manage a lack of it), due to lack of bacteria in the intestinal tract?
Approximately half of the body's requirement of vitamin K is synthesized by bacteria in the lower intestinal tract.
Total parenteral nutrition (TPN) has been ordered for a client. The nurse is aware that the assessment criteria for ordering TPN is what? Select all that apply.
Assessment data to determine if a client is eligible for TPN include inability to absorb nutrients, a debilitating condition lasting more than 2 weeks, and renal or hepatic failure. If the client has an intact gastrointestinal tract then the client should be able to adhere to a regular diet. Tolerating a full-fluid diet also assesses that the gastrointestinal tract is functional and TPN is not warranted.
A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply. Absence of nausea, vomiting Weight gain Bowel sounds within normal range Large amount of gastric residue Absence of diarrhea and constipation Slight abdominal pain and distention
Criteria to consider when evaluating patient feeding tolerance include: absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits.
The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate?
Dehydration can cause increases in hematocrit, BUN, and creatinine. Calorie restriction, increased protein intake, and TPN are not indicated by these laboratory data.
A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate?
Dietary restrictions associated with religions are extremely important to provide culturally competent nursing care. Hindus do not consume beef because cows are considered a sacred creature. They are typically vegetarians; therefore, a vegetable plate is appropriate for this client. Orthodox Jews must have kosher foods. Shrimp and pork are prohibited in this religion. Mormons do not drink coffee, tea, or alcohol and they limit their meat consumption.
What consideration based on gender would a nurse make when planning a menu for a male client with well-defined muscle mass?
Due to the higher percentage in muscle mass in men, they have a higher need for proteins in their diet. Men do not have a lower need for carbohydrates, minerals, or vitamins.
When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?
Eating native food and drinking water in a foreign country may cause problems with digestion and elimination, such as diarrhea. To promote normal bowel elimination, people should drink 2,000 to 3,000 mL of fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation.
Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply.
Examples of those in the United States at risk for an inadequate nutritional intake include older adults who are socially isolated or living on fixed income, homeless people, children of economically deprived parents, pregnant teenagers, people with substance use problems, and clients with eating disorders. Children of middle-income parents and individuals who prefer to purchase food from local farmers are not necessarily at risk.
A nurse is caring for an older adult client who is admitted with failure to thrive. Which laboratory value would the nurse expect to find with this diagnosis?
Failure to thrive includes weight loss and malnutrition. The blood urea nitrogen (BUN) level is low at 15 mg/dL (5.35 mmol/L). This decrease can indicate malnutrition. Normal BUN is 17 to 18 mg/dL (6.07 to 6.43 mmol/L). The serum albumin, prealbumin, and creatinine levels are within normal limits.
A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient?
Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?
Food in the health care setting can often be unattractive and cool. Ensuring that it is appealing to the eyes and presented at the correct temperature can stimulate the client's appetite. Meals should be small and more frequent, not less frequent and larger. Supplements may be nutritionally necessary, but these do not act to increase the client's appetite.
The nurse is providing care for an older adult client who is recovering from pneumonia on the hospital's medical unit. The nurse sets up the client's dinner tray on his overbed table. The client then states, "I won't be having any of this." What is the nurse's most appropriate response?
If a client does not want to eat, the nurse should begin by assessing the reasons behind the client's decision. This should precede any health education that may be needed. It is appropriate to set aside the tray for later, but assessment should take place first.
A nurse documents a client's hemoglobin as 80 g/L. What nutritional condition does this biochemical data signify?
If hemoglobin (normal = 12 to 18 g/dL; 120 to 180 g/L) is decreased, anemia is present. A increased hematocrit signifies dehydration. Malnutrition is related to serum albumin, blood urea nitrogen, and creatinine. Decreased serum albumin also signifies malabsorption.
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube
If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds. Allowing the low intermittent to continue during the assessment will interfere with the auscultation of the sounds. Disconnect of the tube can occur immediately and not for 1 hour prior to the assessment.
The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?
If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.
A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site?
If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage. If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement, except to clean the area.
When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician?
If the stoma is found to be prolapsed, the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal.
A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. Upon inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next?
If there is a large amount of slack between the internal guard and the external bumper, drainage can leak out of the site. In this case, the nurse should apply gentle pressure to tube while pressing the external bumper closer to the skin. Although the nurse should gently rotate the external bumper 90 degrees at least once a day, this action would not address the leaking of the tube. Skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address the leaking, either. There is no need to notify the health care provider regarding this issue.
A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?
If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube.
A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment?
In order to remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective
A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?
In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. "Auscultated abdomen for bowel sounds. Bowel not functioning" is not appropriate as the nurse has diagnosed that the bowel is not functioning which is a medical diagnosis. The documentation lacks the assessment. "Bowel sounds auscultated. Client has no bowel sounds" is not appropriate does not indicate where bowel sounds were auscultated. "Client may have bowel sounds, but they can't be heard" is a subjective statement and does not document the assessment.
A client who is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding?
Intermittent feedings are delivered at regular intervals, using gravity for instillation or a feeding pump to administer the formula over a set period of time. The steps for administering feedings are similar regardless of the tube used. Intermittent feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. Feeding intolerance is less likely to occur with smaller volumes. Feeds are not warmed prior to instillation.
The nurse is caring for a client with a new sigmoid colostomy. The client expresses concern about how to anticipate when a bowel movement will pass into the bag. Which answer is most appropriate?
Irrigations are used to promote regular evacuation of some colostomies. Left-sided colostomies of the descending colon and sigmoid colon can be irrigated successfully for regulating bowel elimination. Telling the client that it is impossible to anticipate when a bowel movement will occur is appropriate for a client with an ileostomy, but not with a sigmoid colostomy. Increasing fiber in the diet will make the stool more solid, but it will not help establish an elimination pattern. Recovering from surgery does not help the bowel elimination pattern to become regular. Irrigating the colostomy is the best way to control when a bowel movement occurs.
A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)?
It is safe for an experienced UAP to empty an ostomy. GI assessment and insertion and irrigation of an NG tube cannot be delegated.
A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?
Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.
The nurse has obtained a client's capillary blood glucose sample and the results are significantly lower than reference range. What is the nurse's priority action?
Low blood sugars should prompt the nurse to assess for signs and symptoms of hypoglycemia. There may or may not be a need to contact the primary care provider depending on whether a protocol is in place and the client's clinical presentation. There is not normally a need to obtain a sample from the opposite hand.
A nurse is conducting client education with a woman who meets the diagnostic criteria for metabolic syndrome. The nurse is teaching the client about the MyPlate tool for promoting healthy food intake. According to MyPlate, the highest proportion of food in each meal should consist of what?
MyPlate recommends the Americans make half of their plate fruits and vegetables. Dairy, proteins, and unsaturated fats are important components of a healthy diet but they should be consumed in smaller quantities than vegetables.
A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?
Normal blood glucose is 80 to 110 mg/dL (4 to 7 mmol/L).
At what period of life do nutrient needs stabilize?
Nutrient needs change across the life span in relation to growth, development, activity, and age. Periods of intense growth and development (such as during infancy, adolescence, pregnancy and lactation) increase nutrient needs. Nutrient needs stabilize during adulthood
The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention?
Older adults who are socially isolated or living on fixed incomes will benefit most from nutritional counseling and intervention. Other individuals are not at the same level of risk
The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?
Placing the client in Fowler's position during an enema will cause the solution to remain in the rectum; expulsion of the solution happens rapidly with minimal cleansing accomplished. The solution should be retained until the desired results are achieved. The solution should not be too hot or too cold, but administered at room temperature. Most people are uncomfortable about discussing the intestinal tract and bowel elimination, so this is an opportune time to discuss it.
The nurse is caring for a client who has been experiencing prolonged wound healing from a surgical procedure. A deficiency in which nutrient would be associated with this condition?
Poor wound healing is associated with deficiencies in vitamin C and protein.
A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube?
Radiographic (x-ray) examination is the only absolutely reliable method to determine accurate tube placement. In the absence of an x-ray, pH testing is predicative of correct placement. Although visualization of aspirated contents can help confirm correct placement of the tube, this method is not as reliable as an x-ray.
A client with constipation has been instructed to increase their fluid intake. The client is unsure what type of fluid he should consume. The nurse's best response is that the client should increase his intake of:
Recommendations to promote regular defecation include a fluid intake of 2,000 to 3,000 mL. Water is recommended as the fluid of choice because fluids containing large amounts of caffeine from ice tea and coffee and sugar from juices may have a diuretic effect. Sports drinks are often used in rehydrate and water should be promoted over sports drinks.
A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?
Serum albumin levels are a good indicator of a client's nutritional status; decreased levels are suggestive of malnutrition. Protein in the client's urine, low blood sugars, and increased white blood cells are not necessarily indicative of malnutrition. Proteinuria is urine having an abnormal amount of protein. The condition is often a sign of kidney disease. Random blood sugar can be affected by food intake. White blood cells are indicative of infection.
A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition
Serum albumin levels can help measure protein levels in the body and are good indicators for nutrition status. Hemoglobin levels maintain red blood cells that carry oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs. Creatinine is a laboratory value that assesses kidney function. Oxygen saturation is the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood. It is best used to determine how well a client is oxygenating.
A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?
Severe vitamin D deficiency manifests as rickets, osteomalacia, poor dentition, and tetany.
The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply
Sodium is found in higher concentrations in table salt, bacon, and processed meats. The other choices do not have a high concentration of sodium.
During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her 6-month-old infant. What does the nurse inform the mother?
Solid foods are generally introduced between 4 and 6 months of age. New foods should be introduced one at a time for a period of 5 to 7 days so that any allergic reaction can be identified. Iron-fortified foods are recommended.
A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?
Specific foods may interact with medications, altering the effectiveness of the drug. Vegetables high in vitamin K decrease the effectiveness of the commonly used anticoagulant warfarin. Calcium, potassium, and Vitamin C do not interact with warfarin.
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:
Stool produced from an ileostomy is liquid and contains large quantities of electrolytes.
A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?
TPN is nutritional therapy that bypasses the gastrointestinal tract and is administered through a central vein. PPN is nutritional therapy used for clients who have an inadequate oral intake and require supplementation of nutrients through a peripheral vein. A PEG is a surgically placed gastrostomy tube. A PEJ is a surgically placed jejunostomy tube.
The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?
Talking during eating increases the risk of aspiration for a client who has dysphagia. Arranging food on the plate in a clock face pattern is a strategy appropriate for a client who is visually impaired. Clients who have dysphagia need to eat slowly and be continually observed for signs of aspiration. Allow enough time for the client to adequately chew and swallow the food. The client may need to rest for short periods during eating.
A nurse nutritionist is collecting assessment data for a patient who complains of "tiredness" and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm?
Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased indicates anemia, if increased indicates dehydration. Serum albumin tests for malnutrition and malabsorption. Protein depletion and malnutrition are diagnosed with serum albumin, prealbumin, transferrin, and blood urea nitrogen tests. The creatinine test may indicate dehydration, reduction in total muscle mass, and severe malnutrition.
The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:
The RDA level is the average dietary intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group.
A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last?
The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation.
A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition?
The client requires peripheral parenteral nutrition. Peripheral parenteral nutrition provides temporary nutritional support of approximately 2000 to 2500 calories daily. It can meet a client's metabolic needs when oral intake is interrupted for 7 to 10 days, or it can be used as a supplement during a transitional period as a client begins to resume eating. Total parenteral nutrition (TPN) is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. Metabolizing nutrition is a way to replenish and supply water to the body. A nasogastric feed is administered through narrow tubing that is inserted through the client's nose into the stomach.
Upon removing the lid of a tray for a client who is lactose intolerant, the nurse discovers which food is not permitted in this client's diet?
The client should not be permitted to eat the custard because it is prepared using milk. Clients who are lactose intolerant cannot digest the simple sugar lactose found in milk and milk products. Chicken is a protein. Lettuce and potato are vegetables.
A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first taKE
The client's last bowel movement was one day earlier, so pharmacologic interventions such as suppositories or enemas are not likely warranted at this time. A change in diet may prove helpful, but the nurse's first action should be to provide a setting that is more conducive to having a bowel movement.
A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client?
The correct nursing diagnosis is Imbalanced Nutrition, Less Than Body Requirement. A clear liquid diet for 5 days would not provide adequate nutrition. It does provide about 1,000 calories but it is below the recommended range from 1,600 to 2,400 calories per day for adult women and 2,000 to 3,000 calories per day for adult men. Risk of injury would be related to movement, thoughts, and/or medications. Fluid volume deficit would be inappropriate as the client is consuming a clear liquid diet and that would provide adequate fluid volume but not enough nutrition. Activity intolerance would also be related to movement by the client.
The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?
The correct sequence for an abdominal assessment is inspection, then auscultation (done before palpation because palpation may disturb normal peristalsis and bowel motility), followed by percussion and palpation. The client should urinate before assessment and the knees should be flexed with the abdomen during the examination.
A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?
The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.
A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?
The head of the bed should be elevated before giving medications or performing a tube feeding. Following this, the placement of the tube should be checked, aspirate the gastric contents with a syringe, and then flush the tube with the ordered amount of water.
A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed?
The hematocrit level of this client is low. Normal hematocrit is 40%-50%. The normal value for hemoglobin is 12-18 mg/dL. The normal value for transferrin is 240-480 mg/dL. The normal blood urea nitrogen is 17-18 mg/dL.
the nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?
The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.
An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis?
The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.
A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?
The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.
Prior to allowing a client to eat, which action is most important for the nurse to take?
The most important thing the nurse can do is to ensure the client is alert enough to safely eat without aspirating. Next, ensuring the client is physically able to self-feed and safely swallow is necessary. The client's cultural needs and eyesight are least important.
The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.
The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan) and yellow are considered abnormal colors for adult stool.
Which procedures can be delegated to an unlicensed assistive personnel (UAP)? Select all that apply.
The nurse may delegate the administration of small-volume and large-volume enemas to UAPs, as well as the administration of enemas until clear. Application of a fecal incontinence device may also be delegated to UAPs. Digital removal of stool is not delegated to unlicensed assistive personnel (UAP). Depending on the state's nurse practice act and the organization's policies and procedures, the digital removal of stool may be delegated to licensed practical/vocational nurses (LPN/LVNs).
A nurse is caring for a client with an ostomy pouch. When should the nurse ask the client to empty the pouch?
The nurse should ask the client to empty the pouch when it is one-third to one-half full, not when it is completely full; otherwise, it may become too heavy and pull the faceplate from the skin. The client need not empty the pouch when he is ready to sleep or have a bath. The pouch is replaced every 4 to 7 days.
Which nursing action associated with successful tube feedings follows recommended guidelines?
The nurse should check the residual before each feeding or every 4 to 8 hours during a continuous feeding. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia. A closed system is the best way to prevent contamination during enteral feedings. The bowel sounds do not have to be assessed as often as 4 times per shift. Once a shift is sufficient. Food dye should not be added as a means to assess tube placement or potential aspiration of fluid.
An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change?
The nurse should suggest eating foods that are attractive and at the proper temperature. Other suggestions include eating one food at a time rather than mixing foods and eating foods with different textures and aromas. The nurse should refrain from suggesting spicy foods, which may not be well tolerated by a client or may not be part of the client's flavor profile.
A nurse is checking a client's capillary blood glucose level. Which nursing action is most appropriate?
The nurse should touch a drop of blood to pad to the test strip without smearing it. Test strips are not cleaned and blood flow is encouraged by warming or stroking the finger, not having the client make a fist. The site should not be wiped with alcohol after testing.
A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply
The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.
An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?
The nurse will caution the client that self-administration of mineral oil to relieve constipation can interfere with absorption of fat-soluble vitamins. The nurse can then further discuss the reason the client is performing this treatment and determine other appropriate interventions to relieve constipation. Reference:
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?
The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.
A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume?
The nurse will recommend brown rice, a food that is high in dietary fiber. Other selections listed do not contain high fiber.
The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening?
The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect.
A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?
The nurse will teach that the FOBT detects heme. It does not test for allergic foods, nor does it test for infection. The fecal immunochemical test (FIT) test results have a high rate of specificity for colorectal cancer.
The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide?
The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.
A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?
The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.
The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure?
The nurse would ensure that the client fasted 6 to 12 hours before the test as per policy. The nurse would not provide a light meal before the test, nor administer two Fleet enemas for an EGD. The client would not ingest a gallon of bowel cleanser. The nurse would not give the client a barium contrast mixture to drink.
Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube?
The nurse would measure the volume and pH of the aspirated fluid, then flush the tube with water. The nurse would not place the client in Trendelenburg position as this could lead to reflux of the feeding from the stomach and possibly cause aspiration of the solution into the lungs. The nurse would not use a small syringe or continue to instill air until fluid is aspirated.
A nurse is assessing the bowel elimination of pediatric clients on the unit. Which developmental factors affecting elimination should the nurse consider? Select all that apply.
The nurse would note that the number of stools that infants pass varies greatly. The number of bowel movements is often related to the feeding the infant is receiving. Breastfed babies often have 2 to 10 stools a day, where formula-fed babies have 1 to 2 stools daily. The nurse would also note that some children have bowel movements only every 2 or 3 days. The nurse would note that constipation is often a chronic problem for older adults. The nurse knows that the voluntary control of defecation occurs between the ages of 18 to 24 months, not 12 to 18 months. A child is likely not constipated if they do not have a daily bowel movement. Children differ in their individual bowel patterns. Liquid stool does not always signify diarrhea in a child. Loose stools may be related to overfeeding.
A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply.
The nurse would place the client in the supine position with the abdomen exposed. The nurse would use a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse would note the character of bowel sounds. The nurse would first inspect, then auscultate, then palpate the abdomen. The nurse would not place the client's legs flat against the bed, rather flex the knees slightly. The nurse would not ask the client to drink fluids to fill the bladder before the exam. The nurse would ask the client to empty the bladder before the exam so as not to have the client uncomfortable from a full bladder.
A nurse who is planning menus for a client in a long-term care facility takes into consideration the effects of foods and fluids on bowel elimination. Which examples correctly describe these effects? Select all that apply.
The nurse would realize that clients who are constipated should eat more fruits and vegetables. The nurse would realize that clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. The nurse would also realize that clients with food intolerances may experience altered bowel elimination. The nurse would realize that a constipated client would not eat eggs and pasta to relieve the constipation; a better choice would be fruits, vegetables, and increased fiber and fluids if not contraindicated. The nurse would realize that alcohol and coffee do not tend to have a constipating effect on clients.
The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?
The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.
Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? You Selected:
The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss
The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.
The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals.
The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.
The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals. Reference:
A student nurse studying human anatomy knows that a structure of the large intestine is the: You Selected:
The small intestine consists of the duodenum, jejunum, and ileum. The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum.
The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?
The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.
A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube?
The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.
The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum?
The tube should be inserted past the external and internal sphincters, approximately 3 in (7.5 cm). Further insertion, such as 5 in (12.5 cm), may damage intestinal mucous membrane. If the tube is inserted less than 3 in (7.5 cm), then the enema solution will not make it into the rectum but will seep out during the administration of the enema.
A client has a history of long-term alcohol use. Which nutrient would need to be required in increased amounts?
The use of alcohol depletes the production of B vitamins in the liver; thus, they would need to be replaced. Calcium is a mineral that is an essential part of bones and teeth. Vitamin C, also known as ascorbic acid and L-ascorbic acid, is a vitamin found in food and used as a dietary supplement. The disease scurvy is prevented and treated with vitamin C-containing foods or dietary supplements. Thiamin is just of the B vitamins that would need to be replaced due to the depletion by alcohol. The other elements of the B Vitamins include the following: B1 Thiamin, B2 Riboflavin, B3 Niacin, B5 Pantothenic Acid, B6 Pyridoxine, B7 Biotin, B9 Folic Acid, and B12 Cobalamin.
The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?
There are many reasons a client may refuse food that is served. The nurse should assess for food preferences, when the client generally eats, whether the client has digestive concerns, and cultural beliefs about foods. Leaving the client alone to eat, or simply delegating feeding, does not encourage intake. The client does not need an appetite stimulant until a full assessment has been conducted and other interventions have been implemented.
The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?
There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.
A paraplegic man receives care in the rehabilitation facility. He confides in a nurse that he has trouble controlling his bowel movements. He tends to normally stool 6 to 8 times per day. This has caused the skin around his rectum to become irritated. Which is not an appropriate NANDA-I diagnosis for this client?
This client is not currently experiencing diarrhea. He does not describe his stools as watery or loose. Rather, this client's problem is with control of the bowel.
A nurse is estimating caloric requirements for a female client whose healthy weight is 120 lb (54.4 kg) and whose activity level is moderate. What will the client's recommended total daily calories be? You Selected:
To calculate the total daily calories for a female client with a healthy weight, take the weight in pounds, and multiply the weight by 10. This would make 1,200 calories. Then look at the activity level. This client's activity level is noted as moderate. This would require the nurse to multiply the total calories (1,200) by 40%. This value (480 calories) would be added to 1,200— a total of 1,680 total daily calories for a 120 lb female with a moderate activity level.
During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply.
To determine the usual patterns of bowel elimination, the nurse asks, "How often do you move your bowels?" To determine if the client needs assistance in bowel elimination, the nurse asks, "Do you use anything to help move your bowels?" The client's social appetite, preference for hot or cold foods, or shopping arena are not questions to ask for bowel elimination.
A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process?
To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.
A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?
To insert a nasointestinal tube, the nurse should measure the tube from the tip of nose to the earlobe and from the earlobe to the xiphoid process and add 8 to 10 in (20 to 25 cm) for intestinal placement. The client should be placed on his or her right side. Analgesia is not normally required in anticipation of placement.
The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?
To promote bowel elimination, the client should consume 20 to 35 g of fiber daily. Foods high in fiber include fresh fruits and vegetables, bran, and whole grains. Cream of wheat is refined cereal and fiber has been removed from apples because of cooking. Other foods low in fiber include soda crackers, chicken noodle soup, tea, and flavored water.
A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced?
Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:
Total parenteral nutrition (TPN) is nutrition administered through a central venous access and is high in nutrients and electrolytes. It is important to assess fluid and electrolyte levels with TPN infusions. Falls are a risk associated with ability to reposition and not TPN. There is no pain associated with TPN infusions as the medication is administered via a central venous access line. Nausea or vomiting are not adverse effects associated with TPN as the medication is administered via a central line and not by a feeding tube in the stomach.
A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?
Usually, 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient; this client is more likely to have liquid stool. If portions of the stool include visible blood, mucus, or pus, include these with the specimen. Also be sure that the specimen is free of any barium or enema solution. Because a fresh specimen produces the most accurate results, send the specimen to the laboratory immediately.
Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor?
Vegetarians have a lower incidence of colorectal cancer and fewer problems with obesity and diseases associated with a high-fat diet. Protein complementation helps a client get amino acids needed. Vegans rely solely on plant sources for protein; semi-vegetarians exclude only red meat from their diet.
A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene?
Vegetarians have a lower incidence of colorectal cancer and fewer problems with obesity and diseases associated with a high-fat diet. Protein complementation involves eating a variety of incomplete plant proteins over the course of the day to provide adequate amounts and proportions of all the essential amino acids present in animal protein sources. Vegans rely solely on plant sources for protein; semi-vegetarians exclude only red meat from their diet.
Which of the following is a fat-soluble vitamin?
Vitamin A, D, E, K
Which vitamin is found only in animal foods?
Vitamin B12 functions in the formation of mature red blood cells and in synthesis of DNA and RNA. This vitamin is only found in animal foods (meats, fish, poultry, milk, and eggs).
Which of the following is a fat-soluble vitamin?
Vitamin E
A client who has bleeding tendencies has a deficiency in which vitamin?
Vitamin K deficiencies are manifested in two ways: an increased tendency to hemorrhage and hemorrhagic disease of the newborn, which is common in premature or anoxic newborns.
Which nutrient is most vital to life?
WATER Water is more vital to life than food because it provides the fluid medium necessary for all chemical reactions, it participates in many reactions, and it is not stored in the body. Water dissolves many solutes and aids digestion, absorption, circulation, and excretion. Foods contain vitamin and minerals. Carbohydrates are any of a large group of organic compounds occurring in foods and living tissues and including sugars, starch, and cellulose.
What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?
Warm water and gentle pressure should be used to unclog a tube. If a large amount of residue is accidentally aspirated, the health care provider should be notified. If the client is nauseated, the head of the bed should remain elevated and an antiemetic administered as prescribed. The tube should be in the stomach, not the esophagus.
A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?
Washing the stoma and surrounding skin with a mild cleanser and water and patting it dry can preserve skin integrity. When using a cleanser, it is important to rinse the area thoroughly. Any residue left on the skin can cause problems with the wafer adhering. Another way to protect the skin is to apply barrier substances such as karaya, a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. Cleaning the stoma with just a dry, cotton bandage is not the correct way of preserving skin integrity.
A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client?
Water should comprise the majority of fluid intake. The remainder should come from food sources such as fruit or 100% fruit juices.
A client admitted with cellulitis of the leg has been prescribed amoxicillin-clavulanate potassium. After 3 days of antibiotic therapy, the client develops severe diarrhea, and the nurse notifies the health care provider. The nurse would anticipate which course of action in response to the client's diarrhea?
When a patient is receiving treatment with broad-spectrum antibiotics, there is a disruption in the normal intestinal flora, allowing the microorganism to flourish within the intestine. C. difficile causes intestinal mucosal damage and inflammation, resulting in diarrhea and abdominal cramping. The antibiotic should be changed but an antidiarrheal medication should not be prescribed because its use would prolong the exposure of the intestinal mucosa to the irritating effect of the antibiotic. Fiber would not be added as this does not change the diarrhea from the antibiotic. The antibiotic is necessary so changing to a different one is best instead of discontinuation of the amoxicillin and administration of an antidiarrheal drug.
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?
When administering an enema, the client's vagus nerve may be stimulated, causing a decrease in the heart rate. The client will exhibit nausea, lightheadedness, dizziness, and clammy skin. The procedure should be stopped, heart rate and blood pressure monitored, and the health care provider notified. The other responses are not appropriate for a client exhibiting a vagal response.
A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly?
When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.
A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs
When enteral feeding is required for a long-term period, an enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy). NG, NI, and Salem Sump tubes will not meet a client's long-term nutritional needs.
A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient?
When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification AND food size and/or consistency.
During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:
When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion prior to auscultation may disturb normal peristalsis and confound the assessment.
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take
When the residual is greater than 500 mL, the enteral feeding should be held and the primary care provider (PCP) needs to be called for further instructions. If there had been two consecutive residuals >250 mL, the PCP would consider ordering a promotility agent. The PCP will consider decreasing the rate of the tube feeding and may or may not want the residual returned since it is so large. The nurse would not discard or replace the residual and merely chart the amount of the residual and continue the tube feeding at the ordered current rate. The excessive large residuals will increase the client's risk for aspiration.
The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.
With a diagnosis of altered body image, a nurse would create interventions for the client becoming more comfortable with the surgical change. When the client is willing to look at the stoma, makes neutral or positive statements about the ostomy, and begins to assist with their care demonstrates that the client is accepting of the body image change that occurred. If the client takes prescribed antidepressants and uses spray deodorant several times an hour means that the has not accepted the change in their body or rather is in denial of the surgical change
A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?
With glucose monitoring, blood from the fingertips shows changes in blood glucose more quickly than other testing sites. With signs and symptoms of hypoglycemia, a fingertip site should be used. Calibrate the glucose monitors at least every month. Glucose levels increase with illness and stress to the body.
A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply.
a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract; and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (McClave et al., 2016; Worthington & Gilbert, 2012). PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.
A woman consumes pasta, grains, and other carbohydrates for which purpose?
for energy
A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition?
he need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.
Which medication causes constipation?
iron supplements A common side effect of iron supplements is constipation. Bisacodyl is a stool softener. Aspirin is an analgesic that does not typically cause constipation. Magnesium antacids help to decrease heartburn and do not typically cause constipation. Reference:
Which task may be safely delegated to unlicensed assistive personnel (UAP)?
Assisting clients to eat may be delegated to UAP. These care providers are normally educated in the risks posed by aspiration. UAP cannot insert or remove NG tubes and they cannot administer tube feedings.
A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed?
A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery.
Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18
A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced.
Which symptom is a known side effect of antibiotics?
A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics.
A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?
Checking for residual before each feeding or every 4 to 6 hours during a continuous feeding according to institutional policy is implemented to identify delayed gastric emptying. Residuals are not measured immediately after a flush.
A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing?
Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. This is unrelated to paralytic ileus or diarrhea; hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Diarrhea is a condition in which feces are discharged from the bowels frequently and in a liquid form. Paralytic ileus is an obstruction of the intestine due to paralysis of the intestinal muscles. Reference:
The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers?
Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor
The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers? You Selected:
Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor.
The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid? You Selected:
Certain foods (e.g., cabbage, onions, legumes) often increase the amount of flatus produced in the intestine. BRUSSEL SPROUTS TOO
The nurse is talking with four members of a family. Which client within the family does the nurse identify that would benefit from discussing a colonoscopy screening with their health care provider?
Colonoscopy screenings should begin at the age of 50 and continue every 10 years thereafter. The 47-year old with a family history of polyps should discuss a colonoscopy screening with the health care provider. Other answers are incorrect
A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?
Complete proteins contain sufficient amounts of the essential amino acids to maintain body tissues and to promote growth
A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?
Consuming megadoses (amounts exceeding those considered adequate for health) of vitamins and minerals can be dangerous. This statement requires further nursing teaching. The other statements do not require further teaching.
A client is discussing vitamin and mineral intake with the nurse. Which client statement requires nursing intervention?
Consuming megadoses of vitamins and minerals can be dangerous, so this statement requires intervention. The nurse should find out the type and dose of vitamins that the client takes. The other statements do not require intervention.
A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk?
Decreased level of consciousness greatly increases a client's risk of aspirating; it is imperative that the nurse assess this prior to the client eating. It is appropriate for the nurse to assess the client's mouth and abdomen and assess for nausea, but none of these actions directly address the client's risk of aspiration.
Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?
Mineral, olive, or cottonseed oil is used to lubricate the stool and intestinal mucosa without distending the intestine. Water and normal saline do not have these qualities. Soap has lubricant properties but primarily acts by irritating the intestinal mucosa.
The nurse is teaching a community group about reading food labels. When teaching about avoidance of refined sugar, the nurse will teach people to avoid foods containing which ingredients
Molasses, corn syrup and corn sweetener, and brown sugar are refined sugars. Honey is a naturally occurring sugar. Therefore, clients do not have to avoid honey.
