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The nurse confirms initial placement of a blindly inserted small-bore NG feeding tube by
a. x-ray.
b. air insufflation.
c. observing patient for coughing.
d. pH measurement of gastric aspirate.
Correct answer: a
Rationale: The nurse should obtain x-ray confirmation to determine whether a blindly placed nasogastric or orogastric tube (small bore or large bore) is properly positioned in the gastrointestinal tract before administering feedings or m
A patient is receiving peripheral parenteral nutrition. The parenteral nutrition solution is completed before the new solution arrives on the unit. The nurse administers
a. 20% intralipids.
b. 5% dextrose solution.
c. 0.45% normal saline solution.
d. 5% l
Correct answer: b
Rationale: If a peripheral parenteral nutrition (PPN) formula bag empties before the next solution is available, a 5% dextrose solution (based on the amount of dextrose in the peripheral PN solution) may be administered to prevent hypogl
A patient with anorexia nervosa shows signs of malnutrition. During initial referring, the nurse carefully assesses the patient for
a. hyperkalemia.
b. hypoglycemia.
c. hypercalcemia.
d. hypophosphatemia.
Correct answer: d
Rationale: Refeeding syndrome is characterized by fluid retention, electrolyte imbalances (e.g., hypophosphatemia, hypokalemia, hypomagnesemia), and hyperglycemia. Conditions that predispose patients to refeeding syndrome include long-st
What is the most common cause of secondary protein-calorie malnutrition in the United States?
a. The unavailability of foods high in protein
b. A lack of knowledge about nutritional needs
c. A lack of money to purchase high-protien foods
d. An alteration
Correct answer: d
Rationale: In the United States, where rote in intake is high and of good quality, protein-calorie malnutrition most commonly results from problems of the GI system. In developing countries, adequate food sources might not exist, the inh
What may occur with failure of the sodium-potassium pump during severe protein depletion?
a. Ascites
b. Anemia
c. Hyperkalemia
d. Hypoalbuminemia
Correct answer: c
Rationale: The sodium-potassium pump uses 20% to 50% of all calories ingested. When energy sources are decreased, the pump fails to function, sodium and water are left in the cell, and potassium remains in extracellular fluids. Hyperkale
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Which patient has the highest risk for poor nutritional balance related to decreased ingestion?
a. Tuberculosis infection
b. Malabsorption syndrome
c. Draining decubitus ulcers
d. Severe anorexia resulting from radiation therapy
Correct answer: d
Rationale: Malnutrition that results form a deceased intake of food is most common in individuals with severe anorexia where there is a decreased desire to eat. Infections created a hypermetabolic state that increases nutritional demand,
The nurse monitors the laboratory results of the patient with protein-calorie malnutrition during treatment. Which result is an indication of improvement in the patient's condition?
a. Decreased lymphocytes
b. Increased serum potassium
c. Increased serum
Correct answer: c
Rationale: Serum transferrin is a protein that is synthesized by the liver and used for iron transport and decreases when there is protein deficiency. An increase in the protein would indicate a more positive nitrogen balance with amino
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The nurse evaluates that patient teaching about a high-calorie, high-protien diet has been effective when the patient selects which breakfast option from the hospital menu?
a. Two poached eggs, hash brown potatoes, and whole milk
b. Two slices of toast wi
Correct answer: a
Rationale: The breakfast with the eggs provides 24 g or protein, compared with 14 g for the protein-fortified cream of wheat and milkshake breakfast. Whole milk instead of skim milk helps to meet the calorie requirements. The toast has 1
When teaching the older adult about nutritional needs during aging, what does the nurse emphasize?
a. Need for all nutrients decreases as one ages.
b. Fewer calories, but the same or slightly increased amount of protein, are required as one ages.
c. Fats,
Correct answer: b
Rationale: Although calorie intake should be decreased in the older adult because of decreased activity and basal metabolic rate, the need for specific nutrients, such as proteins and vitamins, does not change.
When planning nutritional interventions for a healthy 83-year-old man, the nurse recognizes what factor is most likely to affect his nutritional status?
a. Living alone on a fixed income
b. Changes in cardiovascular function
c. An increase in GI motility
Correct answer: a
Rationale: Socioeconomic conditions frequently have the greatest effect on the nutritional status of the healthy older adult. Limited income and social isolation can result in the "tea and toast" meals of the older adult. The other optio
When considering tube feedings for a patient with severe protein-calorie malnutrition, what is an advantage of a gastrostomy tube versus a nasogastric (NG) tube?
a. There is less irritation to the nasal and esophageal mucosa.
b. The patient experiences th
Correct answer: a
Rationale: Standard nasogastric (NG) tubes are used for tube feedings for short-term feeding problems because prolonged therapy can result in irritation and erosion of the mucosa of the upper GI tract. Gastric reflux and the potential fo
Priority Decision: Before administering a bolus of intermittent tube feeding to a patient with a percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220 mL of gastric contents. How should the nurse respond?
a. Return the aspirate to the stomach
Correct answer: b
Rationale: With intermittent feedings, less than 250 mL residual does not require further action. With continuous feedings and a residual of 250 mL or more after the second residual check, a pro motility agent should be considered.
What is an indication for parenteral nutrition that is not an appropriate indication for enteral tube feedings?
a. Head and neck cancer
b. Hypermetabolic states
c. Malabsorption syndrome
d. Protein-calorie malnutrition
Correct answer: c
Rationale: In malabsorption syndrome, foods that are ingested into the intestinal tract cannot be digested or absorbed and tube feedings infused into the intestinal tract would not be absorbed. All of the other conditions can be treated
Priority Decision: The nurse is caring for a patient receiving 1000 mL of parenteral nutrition solution over 24 hours. When it is time to change the solution, 150 mL remain in the bottle. What is the most appropriate action by the nurse?
a. Hang the new s
Correct answer: a
Rationale: Bacterial growth occurs at room temperature in nutritional solutions. Therefore solutions must not be infused for longer than 24 hours. Remaining solution should be discard. Speeding up the solution may cause hyperglycemia and
Priority Decision: An 18-year-old female patient with anorexia nervosa is admitted to the hospital for treatment. On admission she weighs 82 lb (37 kg) and is 5 ft. 3 in (134.6 cm). Her laboratory test results include the following: K+ 2.8 mEq/L (2.8 mmol
Correct answer: d
Rationale: The potential life-threatening cardiac complications related to the hypokalemia are the most important immediate considerations in the patient's care. The other nursing diagnoses are important for the patient's care but do not
The nurse is evaluating the nutritional status of a 55-year-old man who is undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would be the best indicator to determine if the patient has protein-calorie malnutrition?
a. Serum tr
Correct answer: c
Rationale: In the absence of an inflammatory condition, the best indicator of protein-calorie malnutrition (PCM) is prealbumin; prealbumin is a protein synthesized by the liver and indicates recent or current nutritional status. Decrease
A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
a
Correct answer: d
Rationale: Unlicensed assistive personnel (UAP) may position the patient receiving enteral feedings with the head of bed elevated. A licensed practical nurse/licensed vocational nurse (LPN/LVN) or an RN could perform the other activities
An older patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse?
a. Blood glu
Correct answer: b
Rationale: Refeeding syndrome can occur if a malnourished patient is started on aggressive nutritional support. Hypophosphatemia (serum phosphate level less than 2.4 mg/dL) is the hallmark of refeeding syndrome and could result in cardia
The nurse is providing care for a 23-year-old woman who is a strict vegetarian. To prevent the consequences of iron deficiency, what should the nurse recommend?
a. Brown rice and kidney beans
b. Cauliflower and egg substitutes
c. Soybeans and hot breakfas
Correct answer: c
Rationale: Vegetarians are at a particular risk for iron deficiency, a problem that can be prevented by regularly consuming high-iron foods such as hot cereals and soybeans. The other foods listed are not classified as high sources of ir
A patient who has dysphagia as a consequence of a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into this patient's care?
a. Flush the tube with 30 mL of normal salin
Correct answer: b
Rationale: The nurse should flush feeding tubes with 30 mL of water (not normal saline) every 4 hours and before and after medication administration during continuous feeding or before and after intermittent feeding. Flushes of 100 mL ar
A patient received a small-bore nasogastric (NG) tube after a laryngectomy. What should be the nurse's priority intervention before starting the enteral feeding?
a. Aspiration
b. Auscultation of air
c. Set head of bed at 40 degrees.
d. Verify NG tube plac
Correct answer: d
Rationale: It is imperative to ensure that an NG tube is situated in the GI tract rather than the patient's lungs. When an NG tube has been recently inserted, it is important to confirm this placement with an x-ray that will identify the
The nurse recognizes that the majority of patients' caloric needs should come from which source?
a. Fats
b. Proteins
c. Polysaccharides
d. Monosaccharides
Correct answer: c
Rationale: Carbohydrates should constitute between 45% and 65% of caloric needs, compared with 20% to 35% from fats and 10% to 35% from proteins. Polysaccharides are the complex carbohydrates that are contained in breads and grains. Mono
A patient who has suffered severe burns in a motor vehicle accident will soon be started on parenteral nutrition (PN). Which principle should guide the nurse's administration of the patient's nutrition?
a. Administration of PN requires clean technique.
b.
Correct answer: b
Rationale: Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central li
Which assessment should the nurse prioritize in the care of a patient who has recently begun receiving parenteral nutrition (PN)?
a. Skin integrity and bowel sounds
b. Electrolyte levels and daily weights
c. Auscultation of the chest and tests of blood co
Correct answer: b
Rationale: The use of PN necessitates frequent and thorough assessments. Key focuses of these assessments include daily weights and close monitoring of electrolyte levels. Assessments of bowel sounds, integument, peripheral vascular syst
The stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply)?
a. Administer bolus or continuous feedings.
b. Evaluate the nutritional status of the patient.
c. Administer medications th
Correct answer: a, c
Rationale: For the stable patient, the LPN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutritional status of the patient, monitor for complications related t
The patient cannot afford to buy the food she needs for her family, so she makes sure her children eat first, and then she eats. When she comes to the clinic, she reports bleeding gums, loose teeth, and dry, itchy skin. The nurse should know that this pat
Correct answer: b
Rationale: This patient is lacking Vitamin C as evidenced by the bleeding gums, loose teeth, and dry, itchy skin. Clinical manifestations of folic acid deficiency include megaloblastic anemia, anorexia, fatigue, sore tongue, diarrhea, or
When the nurse identifies an individual at risk for malnutrition with nutritional screening, what is the next step for the nurse to take?
a. Supply supplements between meals.
b. Encourage eating meals with others.
c. Have family bring in food from home.
d
Correct answer: d
Rationale: A full nutritional assessment includes history and physical examination and laboratory data. The nutritional assessment will need to be done to provide the basis for nutrition intervention. The interventions may include supple
The patient has parenteral nutrition infusing with amino acids and dextrose. In report, the oncoming nurse is told that the tubing, the bag, and the dressing were changed 22 hours ago. What care should the nurse coming on be prepared to do (select all tha
Correct answer: b,c,e
Rationale: The nurse should check the amount of feeding left in the bag, and that the next bag has been ordered to be sure the solution will not run out before the next bag is available. Parenteral nutrition solutions are only good f
The patient being admitted has been diagnosed with anorexia nervosa. What clinical manifestations should the nurse expect to see on admission assessment?
a. Tan skin, blonde hair, and diarrhea
b. Sensitivity to heat, fatigue, and polycythemia
c. Dysmenorr
Correct answer: d
Rationale: The patient with anorexia nervosa, along with abnormal weight loss, is likely to have hair loss; dry, yellow skin; constipation; sensitivity to cold, and absent or irregular menstruation. Other signs of malnutrition are also n
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