Nokea
A patient has been receiving total parenteral nutrition. Upon assessment, the nurse notes these assessment findings: blood pressure 160/98 mm Hg (elevated from previous readings); pulse rate 110 beats/min and weak; pitting edema on both ankles; and new-onset confusion. The nurse suspects that the patient is experiencing which condition?
- A. Infection
- B. Hypoglycemia
- C. Hyperglycemia
- D. Fluid overload
Correct Answer: D
Rationale: Fluid overload may occur with parenteral nutrition. It is manifested by weak pulse, hypertension, tachycardia, confusion, decreased urine output, and pitting edema.
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A patient is receiving a nutritional supplement via an enteral feeding tube. The nurse will monitor for which common adverse effect?
- A. Diarrhea
- B. Constipation
- C. Fluid overload
- D. Heartburn
Correct Answer: A
Rationale: Diarrhea is the most common result of the gastrointestinal intolerance that occurs with nutritional supplementation.
The nurse is administering a parenteral nutrition infusion to a patient. The nurse will implement which measures to prevent infection? (Select all that apply.)
- A. Change the intravenous tubing set every 72 hours.
- B. Change the intravenous tubing set every time a new bag is added to the infusion.
- C. Use a 1.2-micron filter with each tubing set.
- D. Monitor the patient's temperature every shift during the infusion.
- E. Report any increase in the patient's temperature over 100?°F.
Correct Answer: D,E
Rationale: To prevent infection during parenteral nutrition infusion, the nurse should monitor the patient's temperature every shift and report any increase over 100?°F. Changing the tubing every 24 hours (not 72 hours or with each new bag) and using a 0.22-micron filter (not 1.2-micron) are standard practices, but the options provided are incorrect for infection prevention.
An older adult patient needs to receive an enteral supplement to improve her overall nutritional status. When considering enteral supplements, the nurse notes that which formulation provides complex nutrients?
- A. Ensure Plus
- B. Moducal
- C. ProMod
- D. Microlipid
Correct Answer: A
Rationale: Ensure Plus is a polymeric formulation that contains complex nutrients, including proteins, carbohydrates, and fats. Moducal provides carbohydrates only; ProMod is a protein formulation, and Microlipid supplies only fats.
A patient with a partial bowel obstruction will be given a 1-week course of enteral tube feeding via a nasogastric tube. Which formulation is appropriate for this patient?
- A. An elemental formulation
- B. A polymeric formulation
- C. A formulation for impaired glucose tolerance
- D. A modular formulation that contains carbohydrates
Correct Answer: A
Rationale: Elemental formulations are enteral supplements that require minimal digestion and are indicated for patients with pancreatitis, partial bowel obstruction, irritable bowel disease, and other problems. The other options are incorrect.
When monitoring a patient who has been receiving peripheral parenteral nutrition for more than 3 weeks, the nurse will watch for which potential complication?
- A. Diarrhea
- B. Phlebitis
- C. Hypernatremia
- D. Hypoglycemia
Correct Answer: B
Rationale: The long-term administration of nutritional supplements via a peripheral vein may lead to phlebitis and, possibly, the loss of a limb.