Nokea
What intervention(s) should you prepare for when caring for a patient who is 6 hours post burn with 30% seconddegree burns and absent bowel sounds?
- A. Withholding oral intake
- B. Insertion of an NG tube to low intermittent suction
- C. Starting a diet of clear liquids only
- D. Inserting a feeding tube for nutrition
- E. Feeding the patient a soft diet
Correct Answer: A,B
Rationale: Burns over 20% of total body surface area (TBSA) can lead to paralytic ileus, where the GI tract temporarily stops moving. Absent bowel sounds suggest the GI system is not functioning properly. To prevent vomiting, aspiration, or bowel distension, oral intake is withheld. An NG (nasogastric) tube may be inserted to decompress the stomach and reduce the risk of complications.
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Critically ill, tube-fed patients should have the head of the bed raised to during feedings and for up to 1 hour after feedings.
- A. 5 to 10 degrees
- B. 15 to 25 degrees
- C. 30 to 45 degrees
- D. 50 to 60 degrees
- E. 90 degrees
Correct Answer: C
Rationale: Raising the head of the bed to 30-45 degrees during and after tube feedings reduces the risk of aspiration in critically ill patients.
A patient is receiving TPN via a central venous catheter. The patient's wife is concerned about his care and wants to know why the TPN bag is not changed as often as a regular IV bag of solution would be. You respond by telling her the standard for changing the TPN bag is every:
- A. 6 hours
- B. 8 hours
- C. 12 hours
- D. 24 hours
Correct Answer: D
Rationale: TPN bags are typically changed every 24 hours to minimize infection risk and maintain stability of the nutrient solution.
You are caring for a patient who is scheduled for surgery. Your teaching will include information about nutrition and healing. You will tell the patient which of the following macronutrients is required for tissue repair?
- A. Carbohydrates
- B. Fat
- C. Vitamin E
- D. Protein
- E. Vitamin K
Correct Answer: D
Rationale: Protein is essential for tissue repair and wound healing, as it provides amino acids needed for cell regeneration and collagen formation.
As a home health nurse, you will be caring for the patients noted below. Which patient is at greatest risk for experiencing inadequate nutrition?
- A. A 60-year-old white male recently diagnosed with type 2 diabetes
- B. A 72-year-old widow who had a mild CVA 3 days ago
- C. A 25-year-old mother with two preschoolers who is recovering from a tonsillectomy
- D. A 55-year-old black male recovering at home following coronary artery bypass surgery
Correct Answer: B
Rationale: The 72-year-old widow post-CVA is at greatest risk due to potential swallowing difficulties (dysphagia) and limited ability to prepare meals independently.
You are working in a pediatric clinic when the mother of a 15-year-old female patient calls with concerns about her daughter. Which behaviors she describes would alert you to a possible eating disorder?
- A. She constantly worries about her weight.
- B. She talks about various foods and their nutritional quality.
- C. She exercises 2 to 3 hours daily.
- D. She often complains of a sore throat and indigestion.
- E. She talks frequently with friends about school activities.
Correct Answer: A,C,D
Rationale: Constant weight concern may indicate body image distortion, which is common in eating disorders such as anorexia nervosa. Excessive exercise can be a form of compensatory behavior often seen in both anorexia and bulimia, as individuals attempt to burn off calories consumed. A sore throat and indigestion may result from frequent vomiting, which is a classic sign of bulimia nervosa due to the irritation of the throat and esophagus by stomach acid.