Nokea
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.
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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.
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.
How many grams of protein will the nurse recommend to meet the minimum daily requirement for a patient who weighs 66 kg?
- A. 36
- B. 53
- C. 75
- D. 98
Correct Answer: B
Rationale: The recommended daily protein intake is 0.8-1 g/kg of body weight, which for this patient is 66 kg x 0.8 g = 52.8 or 53 g/day.
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.
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.