Nokea
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.
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The nurse is caring for a comatose patient who is receiving continuous enteral nutrition through a soft nasogastric tube and notes the presence of new crackles in the patient's lungs. In which order will the nurse take the following actions?
- A. Turn off the tube feeding.
- B. Document assessment findings.
- C. Check the tube feeding residual volume.
- D. Notify the patient's health care provider.
Correct Answer: A,C,D,B
Rationale: The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the residual volume because it provides data about possible causes of aspiration. The health care provider should be notified and informed of all the assessment data the nurse has just obtained. Lastly, the nurse documents the assessment findings.
During a busy day, the nurse admits all of the following patients to the medical-surgical unit. Which patients are most important to refer to the dietitian for a complete nutritional assessment?
- A. A 24-year-old who has a history of weight gains and losses
- B. A 53-year-old who complains of intermittent nausea for the past 2 days
- C. A 66-year-old who is admitted for debridement of an infected surgical wound
- D. A 45-year-old admitted with chest pain and possible myocardial infarction (MI)
- E. A 32-year-old with rheumatoid arthritis who takes prednisone daily
Correct Answer: A,C,E
Rationale: Weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest that the patient may be at risk for malnutrition. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.
The nurse is caring for a patient with a body mass index (BMI) of 31 kg/m?², a normal C-reactive protein level, and low transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in which of the following?
- A. Iron
- B. Protein
- C. Calories
- D. Carbohydrate
Correct Answer: B
Rationale: The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.
The nurse is caring for a patient and notes that the peripheral parenteral nutrition (PN) bag has only 20 mL left and a new PN bag has not yet arrived from the pharmacy. Which of the following interventions is priority?
- A. Monitor the patient's capillary blood glucose until a new PN bag is hung.
- B. Flush the peripheral line with saline and wait until the new PN bag is available.
- C. Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy.
- D. Decrease the rate of the current PN infusion to 10 mL/hour until the new bag arrives.
Correct Answer: C
Rationale: To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurse's scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose is appropriate but is not the priority.
Which of the following actions should the nurse implement when using a soft, silicone nasogastric tube for enteral feedings?
- A. Avoid giving medications through the feeding tube.
- B. Flush the tubing after checking for residual volumes.
- C. Administer continuous feedings using an infusion pump.
- D. Replace the tube every 3-5 days to avoid mucosal damage.
Correct Answer: B
Rationale: The soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume. Either intermittent or continuous feedings can be given. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes, but flushing after medication administration is important to avoid clogging.