Nokea
As a home health nurse, you will be caring for the patients noted below. Which patient is at greatest risk for experiencing inadequate nutrition?
- A. A 60-year-old white male recently diagnosed with type 2 diabetes
- B. A 72-year-old widow who had a mild CVA 3 days ago
- C. A 25-year-old mother with two preschoolers who is recovering from a tonsillectomy
- D. A 55-year-old black male recovering at home following coronary artery bypass surgery
Correct Answer: B
Rationale: The 72-year-old widow post-CVA is at greatest risk due to potential swallowing difficulties (dysphagia) and limited ability to prepare meals independently.
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Which actions are taken to verify the correct placement of a small-bore NG tube immediately after insertion? (Rank your answers in the correct order.)
- A. Aspirate the gastric contents, check the pH of contents, and observe the color
- B. Confirm the size of the feeding tube after taping
- C. Place the distal end of the tube in a glass of water and observe for bubbles indicating air exchange
- D. Take an x-ray
- E. Flush the tube with 15 to 30 mL of water to ensure its correct placement
Correct Answer: D,A,B,E,C
Rationale: To verify the correct placement of a small-bore NG tube immediately after insertion, the first and most important step is to obtain an x-ray, as this is the gold standard for confirming placement and must be completed before administering any feedings or medications. Once placement is confirmed radiographically, the nurse can then aspirate gastric contents, checking the pH (which should be between 1 and 5) and observing the color, which is typically grassy green, tan, or off-white, indicating gastric placement. Next, the nurse should confirm the tube size and ensure it is securely taped in place to prevent displacement. After verification, the nurse may flush the tube with 15 to 30 mL of water to confirm patency, but this is done only after placement is confirmed, not as a method of verification itself. The water bubble test, which involves placing the distal end of the tube in water to check for bubbles, is outdated and unreliable and should not be used in current clinical practice.
Critically ill, tube-fed patients should have the head of the bed raised to during feedings and for up to 1 hour after feedings.
- A. 5 to 10 degrees
- B. 15 to 25 degrees
- C. 30 to 45 degrees
- D. 50 to 60 degrees
- E. 90 degrees
Correct Answer: C
Rationale: Raising the head of the bed to 30-45 degrees during and after tube feedings reduces the risk of aspiration in critically ill patients.
You are working in a pediatric clinic when the mother of a 15-year-old female patient calls with concerns about her daughter. Which behaviors she describes would alert you to a possible eating disorder?
- A. She constantly worries about her weight.
- B. She talks about various foods and their nutritional quality.
- C. She exercises 2 to 3 hours daily.
- D. She often complains of a sore throat and indigestion.
- E. She talks frequently with friends about school activities.
Correct Answer: A,C,D
Rationale: Constant weight concern may indicate body image distortion, which is common in eating disorders such as anorexia nervosa. Excessive exercise can be a form of compensatory behavior often seen in both anorexia and bulimia, as individuals attempt to burn off calories consumed. A sore throat and indigestion may result from frequent vomiting, which is a classic sign of bulimia nervosa due to the irritation of the throat and esophagus by stomach acid.
A patient is receiving TPN via a central venous catheter. The patient's wife is concerned about his care and wants to know why the TPN bag is not changed as often as a regular IV bag of solution would be. You respond by telling her the standard for changing the TPN bag is every:
- A. 6 hours
- B. 8 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: TPN bags are typically changed every 24 hours to minimize infection risk and maintain stability of the nutrient solution.
What intervention(s) should you prepare for when caring for a patient who is 6 hours post burn with 30% seconddegree burns and absent bowel sounds?
- A. Withholding oral intake
- B. Insertion of an NG tube to low intermittent suction
- C. Starting a diet of clear liquids only
- D. Inserting a feeding tube for nutrition
- E. Feeding the patient a soft diet
Correct Answer: A,B
Rationale: Burns over 20% of total body surface area (TBSA) can lead to paralytic ileus, where the GI tract temporarily stops moving. Absent bowel sounds suggest the GI system is not functioning properly. To prevent vomiting, aspiration, or bowel distension, oral intake is withheld. An NG (nasogastric) tube may be inserted to decompress the stomach and reduce the risk of complications.