Deck 13: Promoting Nutrition

Question 1

The nurse receives a report stating that a new patient has a nutritional deficit.Which physical clinical indicator consistent with a nutritional deficit does the nurse expect to observe in the patient?

A) Long, shiny hair
B) Pale conjunctivae
C) Pink oral mucosa
D) Firm pink nails

Answer 1

Pale conjunctivae

Question 2

The nurse prepares to insert a small-bore feeding tube into a patient.Which step of the procedure does the nurse expect during the insertion?

A) Advance the tube as patient swallows.
B) The tube coils in the oropharynx.
C) The patient has trouble swallowing.
D) Auscultate during air insufflation

Answer 2

Advance the tube as patient swallows.

Question 3

An older patient has been eating approximately 50% of each meal for several days.Which action does the nurse take to increase the patient's nutritional intake?

A) Serve the food at room temperature.
B) Check for an altered taste perception.
C) Encourage the patient to eat with a friend.
D) Provide soft, bland foods and snacks.

Answer 3

Check for an altered taste perception.

Question 4

The nurse plans care for a patient with impaired swallowing.Which outcome would indicate the priority goal for this patient is being met?

A) The patient holds food in the pockets of the mouth.
B) The nurse observes no movement of the larynx during swallowing.
C) The patient maintains a stabilized weight for 3 consecutive days.
D) The patient's lungs remain clear after eating.

Question 5

The nurse at a community center is preparing a program for older people at risk for malnutrition who need community resources.Which is the best action for initiating the nurse's program?

A) Review each individual's height, weight, and health history.
B) Teach low-cost menus and methods for a balanced diet.
C) Post flyers with instructions for obtaining free vitamins.
D) Provide telephone numbers of food banks and free meals.

Question 6

The nurse prepares a dietary plan for a patient who practices Orthodox Judaism and notes that no Jewish holidays are approaching.What choices does the nurse plan to exclude from the patient's menu?

A) Caffeinated tea
B) Grilled cheese sandwich
C) Milk products
D) Lobster chowder

Question 7

The nurse plans care for four patients and assigns patient feeding to nursing assistive personnel (NAP).Which patient does the nurse watch during mealtime?

A) The patient who refuses most of the meals served.
B) The patient who has learned to use adaptive utensils.
C) The patient who takes a long time to swallow.
D) The patient who is taking ice chips on the first postoperative day.

Question 8

The nurse evaluates the plan of care for a patient who is malnourished.Which assessment finding indicates to the nurse that the plan is effective?

A) The tongue is large with a smooth surface.
B) Eighty percent of food was consumed at the last meal.
C) Patient reports sense of taste has returned.
D) The patient has reddish-pink mucous membranes.

Question 9

The nurse cannot advance the small-bore intestinal feeding tube into the patient's oropharynx.What nursing action will facilitate tube advancement without complications?

A) Attempt to insert the tube into the other naris.
B) Advance the stylet and then thread the tube over it.
C) Remove the stylet, check it for kinks, and reinsert it.
D) Use another stylet to move the tube into position.

Question 10

A patient with a neurological injury resulting in tremors is learning how to feed himself.Which method would the nurse implement to best facilitate learning?

A) Delay self-feeding until the hand tremors subside.
B) Show the patient a video of a man feeding himself.
C) Provide one piece of adaptive equipment at a time.
D) Instruct the patient while assisting him during eating.

Question 11

The patient has weakness of the left arm and hand after a stroke.Which is the best nursing intervention to help maintain the patient's self-esteem during feeding?

A) Delegate feeding to nursing assistive personnel (NAP) to minimize food spillage.
B) Encourage the patient to self-feed as much as possible.
C) Ensure that foods are pureed so they may be consumed through a straw.
D) Collaborate with speech therapist to improve the patient's nutrition.

Question 12

A patient with a neurological disease has difficulty swallowing.Which does the nurse include in the plan of care?

A) Limit oral intake to clear liquids.
B) Allow adequate time for the feeding.
C) Ask family members to coach the patient.
D) Maintain low-Fowler's position for meals.

Question 13

The health care provider has started the patient on a clear liquid diet.Which item does the nurse provide for the patient?

A) Orange juice
B) Ice cream
C) Cranberry juice
D) Vegetable juice

Question 14

The health care provider prescribes a mechanical soft diet for the patient.Which food selection would the nurse provide for the patient?

A) White toast with peanut butter
B) Pancakes with sliced bananas
C) Scrambled eggs with bacon
D) Strained soups and custard

Question 15

A patient has not eaten since admission to the long-term care facility 2 days ago.Which is the best initial intervention for the nurse to prevent malnutrition in this patient?

A) Make a diet request to the health care provider for full liquids.
B) Ask the patient's daughter why the patient will not eat.
C) Remind the patient that nutrition is essential to better health.
D) Assess the patient for possible reasons for the lack of intake.

Question 16

The patient with impaired swallowing begins to choke while eating.Which action would the nurse implement?

A) Suction the airway until clear.
B) Turn the patient to a prone position.
C) Leave the room to get assistance.
D) Instruct the patient to take deep breaths.

Question 17

The nurse prepares to insert a small-bore intestinal feeding tube.Which instruction does the nurse provide to nursing assistive personnel (NAP) to assist with preparation?

A) Immerse the feeding tube in an ice bath.
B) Cut a 10.2-cm (4-inch) piece of adhesive tape.
C) Inspect the patient's nares for irritation.
D) Remove the guidewire from the feeding tube.

Question 18

The nurse admits a patient who follows the Jewish faith and maintains a kosher diet.Which food should the nurse withhold to maintain the patient's dietary practices in accordance with this faith?

A) Pork chops
B) Noodles
C) Rice
D) Tea

Question 19

After nursing teaching, which food identified by the patient reflects an understanding of the soft diet?

A) Hot oatmeal with low-fat milk
B) Tomato stuffed with tuna salad
C) Lean steak with a baked potato
D) Thin spaghetti with tomato sauce

Question 20

The nurse assists the patient who had a recent cerebral vascular accident (CVA or stroke) with drinking water, and the patient begins to choke.Which intervention is the best choice to meet the patient's priority need?

A) Provide oxygen.
B) Suction the patient.
C) Call for assistance.
D) Recline the patient.

Question 21

The nurse prepares to insert a patient's nasogastric tube (NGT) for tube feedings.Which patient assessment requires the nurse to collaborate with the patient's health care provider before initiating the feeding?

A) An intact gag reflex
B) An occluded right naris
C) Impaired swallowing
D) Absent bowel sounds

Question 22

The nurse instructs the caregiver to administer the patient's intermittent tube feeding.Which does the nurse include in caregiver teaching? (Select all that apply.)

A) Maintain tube patency with frequent irrigations.
B) Keep the feeding tube capped between feedings.
C) Complete feeding before checking tube placement.
D) Weigh the patient twice a day for the first month.
E) Store opened cans of formula in the refrigerator.

Question 23

The nurse inserts a gastric feeding tube into the patient.Which method used by the nurse is most accurate to verify placement of the patient's feeding tube?

A) Gets a pH of 4.0 from the feeding tube aspirate.
B) Obtains a pH of 7.0 from the gastric aspirate.
C) Listens at the tube distal to the pyloric sphincter.
D) Locates the tube above the cardiac sphincter.

Question 24

The nurse is unable to aspirate any residual volume from the patient who receives intestinal tube feedings at a rate of 200 mL every 6 hours by intermittent gavage.Which action by the nurse is most appropriate?

A) Insert a nasogastric tube.
B) Withhold the next feeding.
C) Notify the patient's health care provider.
D) Administer the next feeding.

Question 25

The nurse is determining whether an order for a nasogastric tube feeding is appropriate.Which patient diagnosis would prevent the nurse from initiating a tube feeding?

A) Septicemia
B) Pancreatitis
C) Gastric ileus
D) Head trauma

Question 26

The nurse instructs the patient to self-administer nasointestinal tube feedings at home.Which is the best instruction to include in patient teaching about aspirating the tube?

A) Withhold tube feedings if unable to obtain aspirate.
B) Check tube placement by instilling air into the tube.
C) Administer the tube feedings at 7.22° C to 10° C (45° F to 50° F).
D) Report aspirate with a pH less than 6.0 to the provider.

Question 27

After 2 days of administering the patient's continuous nasogastric tube (NGT) feeding at 35 mL/hr successfully, the nurse aspirates 150 mL of formula.Which should the nurse implement first?

A) Return the aspirate and continue with the feeding.
B) Flush the tube with 30 mL of normal saline solution.
C) Return the aspirate and reevaluate patient in 1 hour.
D) Collaborate about the aspirate with the provider.

Question 28

The nurse assesses the patient who receives continuous enteral nutrition through a nasointestinal tube.What is the priority intervention by the nurse if the patient's bowel sounds are inaudible?

A) Document "absent bowel sounds."
B) Gradually decrease the rate of the tube feeding.
C) Monitor the patient for possible diarrhea.
D) Stop the feeding and notify the health care provider.

Question 29

The nurse is planning care for the patient receiving nasogastric tube feedings.What reassessment information would best indicate to the nurse that a successful therapeutic regimen has been established?

A) Respirations are 28-32 breaths/min.
B) The residual volume is less than 100 mL.
C) A stable weight over 1 month.
D) Urine output has increased from 25 to 30 mL/hr.

Question 30

The nurse aspirates fluid from the nasointestinal tube.Which finding requires the nurse to plan follow-up nursing interventions?

A) The aspirated liquid totals 5 mL of greenish fluid.
B) The feeding tube collapses with negative pressure.
C) The nurse aspirates a small amount of the formula.
D) The aspirated liquid appears pale and straw colored.

Question 31

The patient receives a prescription for tube feedings.Which does the nurse implement while inserting a nasogastric tube for this patient?

A) Advances the nasogastric tube while the patient swallows.
B) Instructs the patient about self-care of the feeding tube.
C) Eases insertion by icing down the nasogastric tube.
D) Measures the length from the patient's nose to the sternum.

Question 32

The patient receives three different medications through a nasogastric tube (NGT).Which total fluid volume does the nurse anticipate instilling to administer these medications properly?

A) 30 mL
B) 60 mL
C) 120 mL
D) 150 mL

Question 33

The patient is receiving nasointestinal tube feedings by continuous drip from an open system.Which procedure should the nurse use when caring for this patient?

A) Administer medication with a 10-mL syringe.
B) Change the feeding tube bag every 8 hours.
C) Add enough formula to the bag to last 24 hours.
D) Check the placement of the tube with a 60-mL syringe.

Question 34

The nurse is caring for a patient on intermittent gavage tube feedings.Over what period of time should the nurse infuse each feeding?

A) Up to 8 hours
B) Up to 24 hours
C) 10-15 minutes
D) 30-45 minutes

Question 35

The nurse prepares the patient for discharge to home with instructions to self-administer nasointestinal tube feedings.Which does the nurse include in patient teaching?

A) Infuse the formula at room temperature to avoid abdominal cramping.
B) Increase the amount of free water with persistent diarrhea or constipation.
C) Flush the tube with 500 mL of water after each tube feeding.
D) Allow the formula to infuse for 24-48 hours.

Question 36

Before administering a continuous nasointestinal tube (NIT) feeding, the nurse verifies placement of the patient's NIT and flushes it with water.Which step does the nurse perform next?

A) Instill the formula immediately after removing it from refrigeration.
B) Infuse the formula over 10-15 minutes.
C) Raise the syringe 18 inches above the insertion site.
D) Attach the feeding bag to the proximal end of the NIT.

Question 37

The nurse instructs the new orientee to care for the gastrostomy site.Which items does the nurse include in her teaching? (Select all that apply.)

A) Cleanse the site with Betadine.
B) Place the dressing under the external bar.
C) Assess the site for evidence of drainage or infection.
D) Apply a thin layer of skin barrier to exit site.
E) Use sterile gloves for the procedure.

Question 38

The nurse prepares to insert a nasointestinal tube into a patient.Which does the nurse implement for proper tube placement?

A) Measures from the nose to the earlobe to the xiphoid process.
B) Removes the guidewire after verifying placement.
C) Places the patient on the left side until verifying placement.
D) Anchors the tube with tape after insertion.