Test Bank For Introduction Critical Care Nursing 7th Edition Sole Klein
- Chapter 06: Nutritional Support
Sole: Introduction to Critical Care Nursing, 7th Edition
MULTIPLE CHOICE
1. A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy?
a.
Aspiration pneumonia and sepsis
b.
Sepsis and fluid and electrolyte imbalances
c.
Fluid overload and pulmonary edema
d.
Hypoglycemia and renal insufficiency
ANS: B
Because of the high dextrose concentration, including the fluid and electrolyte content, the patient is placed at high risk for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a potential complication of enteral feedings; sepsis is a potential complication of parenteral nutrition. Fluid overload is possible but unlikely and is not a major complication of parenteral nutrition. Hyperglycemia is more of a concern than hypoglycemia with parenteral nutrition; however, renal insufficiency is not related to parenteral nutrition.
DIF: Cognitive Level: Remember/Knowledge REF: p. 85
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
2. A patient is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement?
a.
To assess for paralytic ileus
b.
To maintain the patency of the feeding tube
c.
To monitor for skin breakdown on the nose
d.
To prevent aspiration of the feedings
ANS: D
Patients who are on a ventilator and who are receiving tube feedings are at a high risk for aspiration and ventilator-associated pneumonia. Assessment of tube placement will neither determine presence of paralytic ileus nor maintain patency. Assessment of tube placement is performed to minimize aspiration risk, not skin breakdown on the nose.
DIF: Cognitive Level: Remember/Knowledge REF: p. 85 | Table 6-4
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
3. The patient is to start parenteral nutrition. The nurse knows to prepare which site for catheter insertion?
a.
Basilic vein
b.
Femoral vein
c.
Radial artery
d.
Subclavian vein
ANS: D
Total parenteral nutrition is administered through a central intravenous line, such as the subclavian vein. Arteries are never used. The femoral site is avoided. The basilic vein is not a central site.
DIF: Cognitive Level: Remember/Knowledge REF: p. 80
OBJ:Discuss practice guidelines related to nutritional support.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
4. A patient has been admitted to the critical care unit after a stroke. After “failing” a swallow study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step?
a.
Administer medications.
b.
Cap off and wait 24 hours before starting feedings.
c.
Obtain a chest radiograph.
d.
Start the tube feeding.
ANS: C
Correct placement must be verified by radiograph before use of the tube for either feeding or administering medications. There is no reason to cap the tube and wait; once placement is verified, the tube can be used.
DIF: Cognitive Level: Apply/Application REF: p. 86 | Table 6-4
OBJ:Discuss practice guidelines related to nutritional support.
TOP:Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
5. A critically ill patient has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this patient to receive?
a.
Arginine
b.
Omega-3 fatty acids
c.
Branched-chain amino acids
d.
Vitamin A
ANS: D
Vitamin A is vital for wound healing. Arginine is also important in wound healing but is more important for trauma and septic patients, as are omega-3 fatty acids. Branched-chain amino acids are very important for stressed patients who have liver dysfunction or ARDS.
DIF: Cognitive Level: Remember/Knowledge REF: p. 82 | Table 6-1
OBJ:Discuss practice guidelines related to nutritional support.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
6. A patient is being fed through a nasogastric tube placed in his stomach. The nurse would carry out which intervention to minimize aspiration risk?
a.
Add blue dye to the formula.
b.
Assess the residual every hour.
c.
Elevate the head of the bed 30 degrees.
d.
Provide feedings via continuous infusion.
ANS: C
The head of the bed should be kept elevated at least 30 degrees if possible during tube feedings to minimize reflux. Blue dye should not be used. Neither continuous feedings nor checking for residual will minimize aspiration.
DIF: Cognitive Level: Apply/Application REF: p. 86 | Table 6-4
OBJ:Discuss practice guidelines related to nutritional support.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
7. A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. What action by the nurse takes priority?
a.
Notify the provider.
b.
Assess the patient’s lungs and oxygen saturation.
c.
Stop the tube feeding.
d.
Slow the rate of the infusion.
ANS: C
Nausea and vomiting are signs of tube feeding intolerance. The nurse should first stop the feeding. Then the nurse can assess for other signs of intolerance and aspiration. After a complete assessment, the nurse would notify the provider.
DIF: Cognitive Level: Apply/Application REF: p. 85
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
8. A patient is receiving enteral feedings and reports fullness and abdominal discomfort. What action by the nurse is best?
a.
Connect the feeding tube to suction.
b.
Continue the tube feeding.
c.
Decrease the tube feeding.
d.
Assess the patient’s gastric residual.
ANS: D
The patient may not be tolerating the tube feeding. The nurse should assess the gastric residual and hold the feeding if it is greater than 500 mL. The other actions are not warranted; the nurse needs further information before proceeding.
DIF: Cognitive Level: Apply/Application REF: pp. 85-86 | Table 6-4
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
9. In addition to residual stomach volume, what other evidence suggests feeding intolerance?
a.
Abdominal distension
b.
Absence of tympany on percussion
c.
Active bowel sounds
d.
Elevated blood glucose by fingerstick
ANS: A
Abdominal distension is expected if the feedings are not being absorbed. Tympany occurs along with distension.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 85-86 | Table 6-4
OBJ:Discuss methods for evaluating nutritional status.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
10. Approximately 5 days after starting tube feedings, a patient develops extreme diarrhea. A stool specimen is collected to check for which possible cause?
a.
Clostridium difficile
b.
Escherichia coli
c.
Occult blood
d.
Ova and parasites
ANS: A
Patients receiving enteral nutrition who develop diarrhea are evaluated for antibiotic- associated causes, including Clostridium difficile.
DIF: Cognitive Level: Remember/Knowledge REF: p. 86 | Table 6-4
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
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