chapter 35 summary questions

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1. A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient’s height is 5′6″ and his current weight is 325 pounds. What would the nurse document as his BMI?

50.5

52.4

54.5

55.2

2. A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to delete per day in order to accomplish this goal?

250 calories

500 calories

750 calories

1000 calories

3. A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process?

Stroke the underside of the patient’s chin to promote swallowing.

Serve meals in different places and at different times.

Offer a whole tray of various foods to choose from.

Avoid between-meal snacks to ensure hunger at mealtime.

4. A 56-year-old male patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating his appetite?

Administering pain medication after meals.

Encouraging food from home when possible.

Scheduling his respiratory therapy before each meal.

Reinforcing the importance of his eating exactly what is delivered to him.

5. A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient?

Feed the patient solids first and then liquids last.

Place the head of the bed at a 30-degree angle during feeding.

Puree all foods to a liquid consistency.

Provide a thirty-minute rest period prior to mealtime.

6. A nurse is evaluating patients to determine their need for total parenteral nutrition (TPN). Which patients would be the best candidates for this type of nutritional support? Select all that apply.

A patient with irritable bowel syndrome who has intractable diarrhea

A patient with celiac disease not absorbing nutrients from the GI tract

A patient who is underweight and needs short-term nutritional support

A patient who is comatose and needs long-term nutritional support

A patient who has anorexia and refuses to take foods via the oral route

A patient with burns who has not been able to eat adequately for 5 days

7. A nurse is feeding a patient who states that she is feeling nauseated and can’t eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?

Remove the tray from the room.

Administer an antiemetic and encourage the patient to take small amounts.

Explore with the patient why she does not want to eat her food.

Offer high-calorie snacks such as pudding and ice cream.

8. A 62-year-old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition?

Vitamin B malnutrition

Obesity

Dehydration

Vitamin C deficiency

9. A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly?

The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site.

The nurse wets a washcloth and washes the area around the tube with soap and water.

The nurse adjusts the external disk every 3 hours to avoid crusting around the tube.

The nurse tapes a gauze dressing over the site after cleansing it.

10. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient’s diet should not be advanced?

The patient consumed 75% of the liquids on her breakfast tray.

The patient tells you she is hungry.

The patient’s abdomen is soft, nondistended, with bowel sounds.

The patient reports fullness and diarrhea after breakfast.

11. A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube?

Auscultate the bowel sounds.

Measure the gastric aspirate pH.

Measure the amount of residual in the tube.

Order radiographic examination of the tube.

12. Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index (BMI) of 18?

Risk for Imbalanced Nutrition: More Than Body Requirements

Imbalanced Nutrition: More Than Body Requirements

Readiness for Enhanced Nutrition

Imbalanced Nutrition: Less Than Body Requirements

13. A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and show signs of respiratory distress. What would be the priority action of the nurse upon this assessment?

Keep the tube in place and notify the primary care provider immediately.

Stop advancing the tube and pull it back into the nasal area.

Ask the patient if he wants the nurse to stop the procedure.

Call for help to perform CPR.

14. A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse’s next action following this assessment?

Use warm water and gentle pressure to remove the clog.

Use a stylet to unclog the tubes.

Administer cola to remove the clog.

Replace the tube with a new one.

15. A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed?

A 19-year-old patient who is a vegan

An elderly patient who takes daily nutritional drinks

A 43-year-old patient who takes ginko bilboa and an aspirin daily

An infant who is breast-feeding

(Taylor 1259-1260)

Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

1. b.

2. d. 1 lb (0.45 kg) of body fat equals about 3,500 cal. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increased or decreased, respectively, by 500 cal (3,500 cal divided by 7 days = 500 cal/day). Similarly, a weight gain or loss of 2 lb (0.9 kg) per week would require an adjustment of 1,000 cal/day.

3. a. To feed a patient with dementia, the nurse should stroke the underside of the patient’s chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

4. b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.

5. d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.

6. a, b, f. Assessment criteria used to determine the need for TPN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract (patient with celiac disease) and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (Worthington & Gilbert, 2012; A.S.P.E.N., 2002). TPN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

7. a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.

8. a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

9. a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.

10. d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.

11. d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement.

12. d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced.

13. b. As the tube is passing through the pharynx and the patient begins to cough and show respiratory distress, the nurse should stop advancing the tube and pull it back into the nasal area. The nurse should also support the patient as he regains normal breathing ability and composure and have him try again if he feels able to.

14. a. In order to remove a clog in a feeding tube, the nurse should try using warm water and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.

15. c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breast-feeding do not adversely affect the outcomes of surgery.

(Taylor 1260-1261)

Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.