Nokea
The nurse is admitting a patient with a body mass index (BMI) of 17 kg/m?² and a low albumin level. Which of the following assessment findings should the nurse expect to find?
- A. Restlessness
- B. Hypertension
- C. Pitting edema
- D. Food allergies
Correct Answer: C
Rationale: Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.
You may also like to solve these questions
The nurse is caring for a patient who has a wound infection after major surgery and has only been taking in about 50% to 75% of the ordered meals. The patient states, 'Nothing on the menu really appeals to me.' Which of the following actions by the nurse will be most effective in improving the patient's oral intake?
- A. Make a referral to the dietitian.
- B. Order at least six small meals daily.
- C. Teach the patient about high-calorie, high-protein foods.
- D. Have family members bring in favourite foods from home.
Correct Answer: D
Rationale: The patient's statement that the hospital foods are unappealing indicates that favourite home-cooked foods might improve intake. The other interventions also may help improve the patient's intake, but the most effective action will be to offer the patient more appealing foods.
The nurse is caring for a patient who is malnourished and is receiving parenteral nutrition (PN) containing amino acids and dextrose for the past 24 hours. The nurse observes that about 50 mL remain in the PN container. Which of the following actions is best for the nurse to take?
- A. Ask the health care provider to clarify the written PN order.
- B. Add a new container of PN using the current tubing and filter.
- C. Hang a new container of PN and change the IV tubing and filter.
- D. Infuse the remaining 50 mL and then hang a new container of PN.
Correct Answer: B
Rationale: All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.
The nurse has just started a patient on continuous tube feedings of a full-strength commercial formula at 100 mL/hour using a closed system method and has had six diarrhea stools the first day. Which of the following actions should the nurse plan to take?
- A. Slow the infusion rate of the tube feeding.
- B. Check gastric residual volumes more frequently.
- C. Change the enteral feeding system and formula every 8 hours.
- D. Discontinue administration of water through the feeding tube.
Correct Answer: A
Rationale: Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.
After 6 hours of parenteral nutrition (PN) infusion, the nurse checks a patient's capillary blood glucose level and finds it to be 6.7 mmol/L. Which of the following actions should the nurse take?
- A. Obtain a venous blood glucose specimen.
- B. Slow the infusion rate of the PN infusion.
- C. Recheck the capillary blood glucose in 4 hours.
- D. Notify the health care provider of the glucose level.
Correct Answer: C
Rationale: Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, notification of the health care provider is not necessary. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.
The nurse is teaching a patient about a high calorie, high protein diet. Which of the following menu choices indicates that the teaching has been effective?
- A. Baked fish with applesauce
- B. Beef noodle soup and canned corn
- C. Fresh vegetables with yogurt topping
- D. Fried chicken with potatoes and gravy
Correct Answer: D
Rationale: Foods that are high in calories include fried foods and those covered with sauces. High protein foods include meat and dairy products. The other choices are lower in calories and protein.