Nokea
The nurse is caring for a patient with anorexia nervosa who is 163 cm tall and weighs 41 kg. Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which of the following nursing diagnoses has the highest priority for the patient?
- A. Risk for activity intolerance as evidenced by physical deconditioning
- B. Risk for electrolyte imbalance as evidenced by insufficient fluid volume
- C. Ineffective health maintenance related to ineffective coping strategies (obsession with body image).
- D. Imbalanced nutrition: less than body requirements related to insufficient dietary intake
Correct Answer: B
Rationale: The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses also are appropriate for this patient but are not associated with immediate risk for fatal complications.
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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.
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.
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 receives change-of-shift report about the following four patients. Which of the following patients should the nurse assess first?
- A. A patient who has malnutrition associated with 4+ generalized pitting edema
- B. A patient whose parenteral nutrition has 10 mL of solution left in the infusion bag
- C. A patient whose gastrostomy tube is plugged after crushed medications were given through the tube
- D. A patient who is receiving continuous enteral feedings and has new-onset crackles throughout the lungs
Correct Answer: D
Rationale: The patient data suggest aspiration has occurred and rapid assessment and intervention are needed. The other patients also should be assessed as quickly as possible, but the data about them do not suggest any immediately life-threatening complications.
The nurse is caring for a patient who is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which of the following actions should the nurse include in the plan of care?
- A. Keep the patient positioned on the left side.
- B. Obtain a daily x-ray to verify tube placement.
- C. Check the gastric residual volume every 4-6 hours.
- D. Avoid giving bolus tube feedings through the PEG tube.
Correct Answer: C
Rationale: The gastric residual volume is assessed every 4-6 hours to decrease the risk for aspiration. The patient does not need to be positioned on the left side. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed. Bolus feedings can be administered through a PEG tube.