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The student nurse is caring for a patient who is receiving intermittent tube feedings. Which of the following actions by the student nurse should cause the RN to intervene in the patient's care?
- A. Positions the head of the bed at 30 degrees.
- B. Flushes the tube before and after the feeding.
- C. Checks residual volume every hour.
- D. Maintains the elevated bed position one hour after the feeding.
Correct Answer: C
Rationale: The residual volume should be checked every 4 hours, not every hour. Elevating the head of the bed to a minimum of 30 degrees, but preferably 45 degrees, prevents aspiration. With intermittent delivery, the head should remain elevated for 30-60 minutes after feeding. The tube is to be flushed before and after the feeding.
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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.
Which of the following actions should the nurse take first in order to improve calorie and protein intake for a patient who eats only about 50% of each meal because of 'feeling too tired to eat much'?
- A. Teach the patient about the importance of good nutrition
- B. Serve multiple small feedings of high-calorie, high-protein foods.
- C. Obtain an order for enteral feedings of liquid nutritional supplements.
- D. Consult with the health care provider about providing parenteral nutrition (PN).
Correct Answer: B
Rationale: Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient's ability to take in more nutrients. Teaching the patient may be appropriate, but will not address the patient's inability to eat more because of fatigue. Tube feedings or PN may be needed if the patient is unable to take in enough nutrients orally, but increasing the oral intake should be attempted first.
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 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 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.