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The nurse is caring for a patient who is receiving continuous enteral nutrition through a small-bore silicone feeding tube, has a computed tomography (CT) scan ordered, and will have to be placed in a flat position for the scan. Which of the following actions by the nurse is best?
- A. Shut the feeding off 30-60 minutes before the scan.
- B. Ask the health care provider to reschedule the CT scan.
- C. Connect the feeding tube to continuous suction during the scan.
- D. Send the patient to CT scan with oral suction in case of aspiration.
Correct Answer: A
Rationale: The tube feeding should be shut off 30-60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.
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The nurse is caring for a patient with protein calorie malnutrition who has had abdominal surgery and is receiving parenteral nutrition (PN). Which of the following findings is the best indicator that the patient is receiving adequate nutrition?
- A. Blood glucose is 6.1 mmol/L.
- B. Serum albumin level is 35 g/L.
- C. Fluid intake and output are balanced.
- D. Surgical incision is healing normally.
Correct Answer: D
Rationale: Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.
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 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 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.
The nurse is admitting a patient for electrolyte disorders of unknown etiology. Which of the following findings is most important to report to the health care provider?
- A. The patient's knuckles are macerated.
- B. The patient uses laxatives on a daily basis.
- C. The patient has a history of weight fluctuations.
- D. The patient's serum potassium level is 2.2 mmol/L.
Correct Answer: D
Rationale: The low serum potassium level may cause life-threatening cardiac dysrhythmias and potassium supplementation is needed rapidly. The other information also will be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.