Introduction Critical Care Nursing 7th Edition Sole Klein-Test Bank

Exam Aid For Critical Care Nursing Introduction 7th Edition Sole Klein

ISBN-10:0323377033 , ISBN-13:978-0323377034

Chapter 06: Dietary Aid
Sole: Critical Care Nursing Introduction, 7th Edition

MULTIPLE CHOICE

1. A patient is encountering complications post stomach surgery and is on NPO status. Due to the inability to administer enteral tube feedings, the decision is made to initiate parenteral feedings. What are the primary concerns for this treatment?

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

Given the high dextrose concentration and the fluid and electrolyte composition, the patient is at a significant risk for sepsis and fluid and electrolyte imbalances. Although aspiration pneumonia could be a complication of enteral feedings, sepsis is more likely with parenteral nutrition. While fluid overload is a potential issue, it is not a major complication of parenteral nutrition. Hyperglycemia is a bigger concern than hypoglycemia with parenteral nutrition; nonetheless, renal insufficiency is not linked to parenteral nutrition.

DIF: Cognitive Level: Recall/Information REF: p. 85

OBJ: Outline strategies for monitoring and assessing the nutrition care plan.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

2. A patient on a ventilator has been commenced on nasogastric small-bore feeding tube for enteral feedings. Why is it essential for the nurse to consistently verify tube placement?

a. To evaluate 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

Ventilated patients receiving tube feedings are at a heightened risk for aspiration and ventilator-associated pneumonia. Checking tube placement does not address the presence of paralytic ileus or patency. Assessing tube placement is crucial to minimize the risk of aspiration, not skin breakdown on the nose.

DIF: Cognitive Level: Recall/Information REF: p. 85 | Table 6-4

OBJ: Outline strategies for monitoring and assessing the nutrition care plan.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

3. The patient is scheduled for parenteral nutrition. The nurse is aware to prep which site for catheter insertion?

a. Basilic vein
b. Femoral vein
c. Radial artery
d. Subclavian vein

ANS: D

Complete parenteral nutrition is administered via a central intravenous line, such as the subclavian vein. Arteries are never utilized. The femoral site is avoided. The basilic vein is not a central site.

DIF: Cognitive Level: Recall/Information REF: p. 80

OBJ: Discuss practice guidelines related to dietary support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Following a stroke, a patient is found to have dysphagia and is put on enteral feedings. After inserting a nasogastric tube for tube feeding, what is the next crucial step?

a. Administer medications.
b. Cap off and wait 24 hours before initiating feedings.
c. Obtain a chest radiograph.
d. Begin the tube feeding.

ANS: C

Before using the tube for feeding or medication administration, proper placement must be confirmed through radiography. There is no need to cap the tube and wait; once placement is confirmed, the tube can be utilized.

DIF: Cognitive Level: Application REF: p. 86 | Table 6-4

OBJ: Discuss practice guidelines related to dietary support.

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

5. A critically ill patient has a nonhealing wound and malnutrition. What dietary supplementation component is most crucial 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 critical in wound healing but more so for trauma and septic patients, as are omega-3 fatty acids. Branched-chain amino acids are essential for stressed patients with liver dysfunction or ARDS.

DIF: Cognitive Level: Recall/Information REF: p. 82 | Table 6-1

OBJ: Discuss practice guidelines related to dietary support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

6. A patient is receiving enteral feedings through a nasogastric tube in the stomach. What intervention should the nurse perform to reduce aspiration risk?

a. Add blue dye to the formula.
b. Evaluate the residual every hour.
c. Elevate the head of the bed 30 degrees.
d. Administer feedings through continuous infusion.

ANS: C

During tube feedings, keeping the head of the bed elevated at least 30 degrees helps minimize reflux. Blue dye is not advisable. Continuous feedings or residual checks will not decrease aspiration.

DIF: Cognitive Level: Application REF: p. 86 | Table 6-4

OBJ: Discuss practice guidelines related to dietary support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

7. A patient on continuous enteral feedings has vomited 250 mL of milky green fluid. What should the nurse prioritize?

a. Inform the provider.
b. Assess the patient’s lungs and oxygen saturation.
c. Halt the tube feeding.
d. Slow the rate of the infusion.

ANS: C

Vomiting during tube feeding indicates intolerance. The nurse should first stop the feeding. Subsequently, other signs of intolerance and aspiration can be assessed. Following a comprehensive evaluation, the nurse would then contact the provider.

DIF: Cognitive Level: Application REF: p. 85

OBJ: Describe strategies for monitoring and assessing the nutrition care plan.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

8. A patient develops fullness and abdominal discomfort while receiving enteral feedings. What action by the nurse is most appropriate?

a. Connect the feeding tube to suction.
b. Maintain the tube feeding.
c. Reduce the tube feeding.
d. Evaluate the patient’s gastric residual.

ANS: D

If the patient is not tolerating the tube feeding, the nurse should assess the gastric residual and discontinue the feeding if it exceeds 500 mL. The other actions are not justified; more information is needed before proceeding.

DIF: Cognitive Level: Application REF: pp. 85-86 | Table 6-4

OBJ: Describe strategies for monitoring and assessing the nutrition care plan.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

9. Besides gastric residual volume, what additional evidence indicates feeding intolerance?

a. Abdominal distension
b. Absence of tympany on percussion
c. Active bowel sounds
d. Increased blood glucose by fingerstick

ANS: A

Abdominal distension is expected if the feeds are not being absorbed. Tympany accompanies distension.

DIF: Cognitive Level: Recall/Information REF: pp. 85-86 | Table 6-4

OBJ: Discuss methods for evaluating nutritional status.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

10. About 5 days post initiation of tube feedings, a patient develops severe diarrhea. A stool sample is collected to investigate for which possible cause?

a. Clostridium difficile
b. Escherichia coli
c. Occult blood
d. Ova and parasites

ANS: A

In cases where patients receiving enteral nutrition develop diarrhea, assessments are made to determine antibiotic-related causes, including Clostridium difficile.

DIF: Cognitive Level: Recall/Information REF: p. 86 | Table 6-4

OBJ: Discuss strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

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