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High Acuity Nursing 7th Edition Wagner Hardin-Pierce Test Bank

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High Acuity Nursing 7th Edition Wagner Hardin-Pierce Test Bank

ISBN-13: 978-0134459295
ISBN-10: 0134459296

 

 

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High Acuity Nursing 7th Edition Wagner Hardin-Pierce Test Bank

ISBN-13: 978-0134459295
ISBN-10: 0134459296

 

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Free Nursing Test Questions:

High Acuity Nursing, 7e (Wagner)

Chapter 6   Nutrition Support

 

1) A patient is admitted to the intensive care unit with hepatic failure. The nurse would encourage the patient to eat which item from the provided lunch?

  1. Whole milk
  2. Pasta with tomato sauce
  3. Salad with oil and vinegar dressing
  4. Mixed fruit with whipped cream

Answer:  2

Explanation:  1. The patient should reduce fat caloriesRemember, low-fat milk is a better option.

  1. Patients with liver failure benefit from a high carbohydrate intake.
  2. Patients in liver failure should follow a low-fat diet.
  3. Whipped cream is high in fat.

Page Ref: 117

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

LO & MNL LO:  LO01: Explain nutritional alterations associated with selected disease state.

 

 

2) A patient with a body mass index (BMI) of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse’s focus regarding this patient’s nutritional needs?

  1. Support elevated protein needs.
  2. Maintain on intravenous fluids and clear liquids.
  3. Limit food and fluid intake to three mealtimes daily.
  4. Begin a weight-reduction program immediately.

Answer:  1

Explanation:  1. During acute illness, it is crucial to meet the elevated protein needs of obese patients to optimize outcomes.

  1. No patients should be maintained for long periods on IV fluid and clear liquids alone.
  2. There is no reason to limit food to three daily meals. Fluids should not be restricted unless there is a comorbid condition that requires decrease in fluid intake.
  3. Weight loss is not the focus of the postoperative period.

Page Ref: 120

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

LO & MNL LO:  LO01: Explain nutritional alterations associated with selected disease state.

 

3) A patient was admitted to the ICU for treatment of heart failure. Which dietary regimen would the nurse provide?

  1. Restricted sodium of no more than 1 g/day
  2. Multiple small meals throughout the day
  3. Clear liquids for the first 24 hours
  4. Low-potassium foods

Answer:  2

Explanation:  1. Sodium should not be restricted lower than 2 g/day.

  1. Presence of food in the gastrointestinal tract can stress the already failing heart. Multiple small meals throughout the day are preferable to three large meals.
  2. Unless required by a comorbidity, there is no rationale for a clear liquid diet. Total consumption of liquids may need to be monitored.
  3. Diuretics used to manage heart failure may result in hypokalemia. Restriction of potassium-bearing foods is not indicated.

Page Ref: 120

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

LO & MNL LO:  LO01: Explain nutritional alterations associated with selected disease state.

 

 

4) The nurse is planning a refeeding program for a patient diagnosed with cachexia from AIDS. Which nursing interventions are indicated?

  1. Encourage the patient to eat as much as possible during each meal.
  2. Initiate feeding as half of goal rate.
  3. Limit the patient’s intake of fluids so to encourage a normal appetite.
  4. Establish baseline phosphorus, potassium, and magnesium levels.

Answer:  4

Explanation:  1. If the patient ingests as much food as possible during each meal, the risk of refeeding syndrome will increase.

  1. Nutritional support should be initiated at 25% of goal.
  2. Restriction of fluids is not indicated, will not necessarily stimulate a normal appetite, and may place the patient at risk for fluid volume deficit.
  3. Refeeding syndrome may result in hypophosphatemia, hypokalemia, and hypomagnesemia. Baseline levels should be established and frequently monitored.

Page Ref: 132

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

LO & MNL LO:  LO04: Describe refeeding syndrome and prevention strategies.

 

5) The nurse is caring for a patient with a history of hypercapnea. What should the nurse include when planning for this patient’s nutritional needs?

  1. Monitor carbohydrate intake to reduce body carbon dioxide levels.
  2. Encourage fat intake.
  3. Minimize vitamin supplements.
  4. Limit protein.

Answer:  1

Explanation:  1. Limiting the carbohydrate intake in a patient with a history of hypercapnea would be beneficial in efforts to reduce the body’s carbon dioxide load.

  1. Fat is calorie intense and patients with excessive overall calorie intake may have increased carbon dioxide levels.
  2. Vitamin supplements should be provided according to the patient’s needs and not minimized unless necessary.
  3. The patient’s protein should not be limited but rather calculated to meet the patient’s needs.

Page Ref: 117

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

LO & MNL LO:  LO01: Explain nutritional alterations associated with selected disease state.

 

 

6) The nurse is caring for a patient diagnosed with chronic renal failure. The patient is not on dialysis and currently weighs 100 kg. What would be an appropriate intake of protein for this patient?

  1. 120 g per day
  2. 50 g per day
  3. 240 g per day
  4. 60 g per day

Answer:  4

Explanation:  1. 120 g of protein is 1.2 g/kg and is too high for this patient.

  1. 50 g of protein is equal to 0.5 g/kg, which is too low for this patient.
  2. 240 g of protein is equal to 2.4 g/kg, which is too high for this patient.
  3. The patient with renal failure who is not receiving maintenance hemodialysis would benefit from receiving a protein intake of 0.6 to 0.8 g/kg per day. The patient weighs 100 kg and therefore a daily intake of 60 g of protein per day would be appropriate.

Page Ref: 117

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

LO & MNL LO:  LO01: Explain nutritional alterations associated with selected disease state.

 

7) A patient who has a history of anorexia is brought to the emergency department after passing out at work. Which strategy for refeeding this patient would the nurse anticipate?

  1. Immediate placement of an enteral feeding tube
  2. Placement of a parenteral feeding line within 24 hours
  3. Efforts to stabilize serum electrolytes prior to refeeding
  4. Stabilization of BUN and creatinine prior to refeeding

Answer:  3

Explanation:  1. An enteral feeding tube may be indicated, but it is not an immediate need.

  1. A parenteral feeding tube may be indicated, but it is not an immediate need.
  2. Serum electrolytes, particularly potassium, phosphorus, and magnesium, should be stabilized prior to refeeding.
  3. Irregularities in BUN and creatinine would be addressed, but there is no indication that this is a priority prior to refeeding.

Page Ref: 132

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

LO & MNL LO:  LO04: Describe refeeding syndrome and prevention strategies.

 

 

8) The nurse is caring for a patient who sustained burns of 40% of the total body surface area. What would the nurse plan to meet this patient’s nutritional needs?

  1. Supply with balanced nutrients to meet current body weight needs.
  2. Complete a nutritional assessment and supply with high-calorie, high-protein supplements.
  3. Provide high-dose therapy of vitamins C and B.
  4. Supply with high-fat and high-carbohydrate supplements.

Answer:  2

Explanation:  1. Because of the hypermetabolic status of the patient, the patient needs more calories than those needed to meet current body weight needs.

  1. The patient recovering from a burn injury of 40% of the total body surface should have a complete nutritional assessment and then be supplied with high-calorie, high-protein supplements to meet the body’s hypermetabolic and healing needs.
  2. Standardized protocols for vitamin supplementation should be followed. Research does not support routine use of anabolic agents or specific nutrients.
  3. High fat and high carbohydrate are not the primary needs for this patient.

Page Ref: 120

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

LO & MNL LO:  LO01: Explain nutritional alterations associated with selected disease state.

 

9) The nurse is caring for a patient who is comatose after a traumatic brain injury. What is important for the nurse to include when planning for this patient’s nutritional needs?

  1. Provide adequate calories in the form of carbohydrates and fats.
  2. Ensure adequate protein intake to maintain a positive nitrogen balance.
  3. Plan to implement parenteral nutrition as soon as possible.
  4. Increase dietary supply of cortisol.

Answer:  2

Explanation:  1. Calories should be provided to support all nutritional needs and not focus on carbohydrates and fats.

  1. In the patient with a traumatic brain injury, providing adequate energy and protein for a positive nitrogen balance is paramount to successful treatment, and aggressive nutrition support is recommended.
  2. Because patients with traumatic brain injury often have poor cough or gag reflex, they are at risk of pulmonary aspiration. Enteral nutrition is the preferred alternative to oral nutrition.
  3. Patients with traumatic brain injury have massive release of catecholamines and cortisol. Cortisol is not added by nutritional means.

Page Ref: 121

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Physiological Adaptation

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

LO & MNL LO:  LO01: Explain nutritional alterations associated with selected disease state.

 

10) A patient in the intensive care unit has been NPO, taking nothing by mouth, for several days. The nurse is unable to assess bowel sounds. What should be included in the plan to support this patient’s nutritional needs?

  1. Maintain NPO status.
  2. Prepare to assist with implementation of a large bore venous access device to support total parenteral nutrition.
  3. Determine best enteral feeding approach and plan implementation.
  4. Begin oral feeding with a diet as tolerated as soon as bowel sounds return.

Answer:  3

Explanation:  1. The patient should not be maintained on NPO status only because of the absence of bowel sounds.

  1. Total parenteral nutrition might expose the patient to unnecessary pathogens, which could compromise the healing process.
  2. Readiness for enteral feeding should not be determined by the presence of bowel sounds. Active bowel sounds have been used as criteria to initiate feeding, but there is no scientific evidence to support this practice. Bowel sounds are a poor indicator of small bowel motility and nutrient absorption, as they are the result of air passing through the intestinal tract.
  3. The patient may or may not be able to tolerate oral feedings with a diet as tolerated. Nutritional support should not wait until the presence of bowel sounds.

Page Ref: 121

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

LO & MNL LO:  LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

 

11) The nurse is assessing a patient’s ability to receive enteral feedings. Which findings would the nurse evaluate as potential contraindications to this intervention?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

  1. The patient has a history of Crohn’s disease.
  2. The patient has a gastric ulcer.
  3. There is a mechanical obstruction.
  4. The patient has developed hemorrhagic pancreatitis.
  5. The patient has had severe intractable diarrhea for 3 days.

Answer:  3, 4, 5

Explanation:  1. History of Crohn’s disease is not a contraindication for enteral therapy.

  1. Presence of gastric ulcer is not a contraindication to enteral feeding but may be a determinant of type of feeding tube chosen.
  2. Contraindications to enteral nutrition have diminished as its safety and efficacy have been demonstrated in many types of high-acuity patients. Mechanical obstruction is the only absolute contraindication to enteral feedings.
  3. Severe hemorrhagic pancreatitis is a relative contraindication to enteral feeding.
  4. Severe intractable diarrhea is a relative contraindication to enteral feeding.

Page Ref: 122

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

LO & MNL LO:  LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

 

12) A patient, with a history of aspiration pneumonia, is going to receive enteral feedings. What nursing interventions should be implemented?

  1. Add a bit of food coloring to the bag of enteral feeding to help assess for aspiration.
  2. Use a chlorhexidine mouth rinse during oral care.
  3. Position the head of the patient’s bed at 30 degrees.
  4. Avoid suctioning the patient while feedings are in progress.

Answer:  2

Explanation:  1. Dye should not be added to the enteral feeding. Dye lacks the required sensitivity for assessment and has been associated with several adverse events.

  1. Use of chlorhexidine mouth rinse helps to reduce oral colonization.
  2. The patient’s head should be elevated to at least 30 degrees. Elevating the head of the bed does not guarantee the patient’s position.
  3. Presence of enteral feedings does not preclude suctioning if it is indicated.

Page Ref: 126

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning

LO & MNL LO:  LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

 

 

13) A newly employed nurse reports that a patient receiving nasogastric tube feedings has a gastric residual volume of 450 mL. Which nursing intervention is indicated?

  1. Hold the tube feeding until the gastric aspirate is less than 100 mL.
  2. Provide the tube feeding as a bolus.
  3. Continue the feeding but increase assessment for intolerance.
  4. Reposition the enteral tube.

Answer:  3

Explanation:  1. It is not necessary to wait until the gastric residual volume is less than 100 mL since this is a nasogastric tube and not a gastrostomy tube.

  1. Introducing a bolus feeding would quickly increase the amount of feeding in the stomach and is not indicated.
  2. The current recommendation is to eliminate routine gastric residual volume measurement and to continue feeding unless overt signs of regurgitation, vomiting, or aspiration occur.
  3. Repositioning of the enteral tube is not indicated.

Page Ref: 125

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

LO & MNL LO:  LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

 

14) A patient has an occluded postpyloric feeding tube. Which nursing intervention is indicated?

  1. Irrigate the tube with a large amount of pressure to break the clog.
  2. Pull the tube and insert another.
  3. Slowly attempt to irrigate the tube with warm water.
  4. Use a stylet to break through the clog.

Answer:  3

Explanation:  1. The nurse should not irrigate the tube with large amounts of pressure.

  1. Efforts should be undertaken to dislodge the clog before the tube is changed.
  2. To dislodge a clogged tube, irrigate the tube with warm water. Also, using a syringe with alternating positive and negative pressure can dislodge a clog.
  3. Using a stylet to break up a clog can cause an esophageal or gastric mucosa tear.

Page Ref: 126

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

LO & MNL LO:  LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.

 

15) The nurse is caring for a patient with a central venous catheter for total parenteral nutrition. Which findings would indicate to the nurse that the patient might be experiencing central line-associated bloodstream infection (CLABSI)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

  1. Sudden glucose intolerance
  2. Leukocytosis
  3. Sudden onset of chills
  4. Sudden onset chest pain
  5. Tenderness at the insertion site

Answer:  1, 2, 3, 5

Explanation:  1. Sudden glucose intolerance may occur up to 12 hours before a temperature elevation occurs and is an indicator of catheter-related sepsis.

  1. Leukocytosis will occur as the patient’s immune system begins to fight the infection.
  2. The patient may be experiencing chills for several reasons, but the nurse should consider the possibility of catheter-related sepsis.
  3. Sudden onset chest pain may occur if a pneumothorax develops but is not associated with catheter related sepsis.
  4. Infection at the site of insertion can be manifested by tenderness or erythema.

Page Ref: 130

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

LO & MNL LO:  LO03: Discuss the parenteral methods used to provide nutrition for the high-acuity patient, including potential complications.

 

16) A patient receiving total parenteral nutrition has elevated serum blood urea nitrogen and serum sodium levels. The nurse would conduct additional assessment for which complication?

  1. Prerenal azotemia
  2. Hyperglycemia
  3. Central line-associated bloodstream infection (CLABSI)
  4. Hepatic dysfunction

Answer:  1

Explanation:  1. Prerenal azotemia is caused by overaggressive protein administration and is aggravated by underlying dehydration. Presenting signs and symptoms include an elevated serum BUN, serum sodium, and clinical signs of dehydration.

  1. Hyperglycemia is indicated by blood glucose level of greater than 180 mg/dL while receiving total parenteral nutrition.
  2. Signs and symptoms of catheter-related sepsis include sudden onset of fever, rigors, or chills that coincide with parenteral infusion; erythema, swelling, tenderness, or purulent drainage from the catheter site; sudden temperature elevation that resolves on catheter removal; leukocytosis; sudden glucose intolerance that may occur up to 12 hours before temperature elevation; and bacteremia/septicemia/septic shock.
  3. Hepatic dysfunction would be assessed with serum liver function tests and bilirubin levels.

Page Ref: 130

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

LO & MNL LO:  LO03: Discuss the parenteral methods used to provide nutrition for the high-acuity patient, including potential complications.

 

17) After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea. The nurse is concerned that pneumothorax may be occurring. Which assessment findings would support this concern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

  1. Restlessness
  2. Chest pain
  3. Decrease in pulse oximetry reading
  4. Severe headache
  5. Combativeness

Answer:  1, 2, 3

Explanation:  1. Restlessness may occur as pneumothorax increases in size.

  1. Chest pain is a common finding during pneumothorax.
  2. Hypoxia will occur as pneumothorax size increases.
  3. Headache is not associated with development of pneumothorax.
  4. Combativeness is not a common result of pneumothorax.

Page Ref: 131

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

LO & MNL LO:  LO03: Discuss the parenteral methods used to provide nutrition for the high-acuity patient, including potential complications.

 

18) A patient is suspected of having an air emboli from a central venous line inserted for total parenteral nutrition. What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

  1. Place the patient on the left side.
  2. Place the patient in Trendelenburg position.
  3. Occlude the catheter nearest to the entry site of the skin.
  4. Notify the physician and prepare to take the patient to surgery.
  5. Prepare to assist with chest tube insertion.

Answer:  1, 2, 3

Explanation:  1. When air embolus is suspected, immediate action is required. The patient should be placed on the left side. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.

  1. When air embolus is suspected, immediate action is required. The patient should be placed in the Trendelenburg position. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.
  2. The nurse should prevent additional air from entering the circulatory system by occluding the catheter as close as possible to where it enters the skin.
  3. Surgical intervention is not necessary.
  4. Chest tubes are not used in the treatment of air embolism.

Page Ref: 131

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

LO & MNL LO:  LO03: Discuss the parenteral methods used to provide nutrition for the high-acuity patient, including potential complications.

 

19) The nurse is concerned that refeeding syndrome may be occurring in a patient receiving enteral nutrition. Which laboratory values would support this concern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

  1. Serum potassium is 3.4 mEq/L
  2. Fasting blood glucose is 98 mg/dL
  3. Hemoglobin is 10.8 g/100 mL
  4. Serum sodium of 138 mEq/L
  5. Chloride of 98 mmol/L

Answer:  1, 3

Explanation:  1. Hypokalemia is one of the electrolyte imbalances associated with refeeding syndrome.

  1. Hyperglycemia is more likely to occur with refeeding syndrome.
  2. Anemia can occur because of refeeding syndrome.
  3. This is a normal serum sodium level.
  4. This is a normal chloride level.

Page Ref: 132

Cognitive Level:  Analyzing

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

LO & MNL LO:  LO04: Describe refeeding syndrome and prevention strategies.

 

 

20) A patient has been started on tube feeding by nasogastric tube. When his wife visits, she says, “I need to tell you that my husband is lactose intolerant so that feeding will make him sick.” What nursing response is indicated?

  1. “Even though the tube feeding fluid looks like milk it is lactose-free.”
  2. “We did not know that. I will contact his physician immediately.”
  3. “Since he is being fed by tube, the fact that he is lactose intolerant is not an issue.”
  4. “We will watch to see if he has any symptoms of lactose intolerance.”

Answer:  1

Explanation:  1. Commonly used tube feedings are lactose free.

  1. There is no need to contact the physician.
  2. The process of tube feeding does not change the concern over the patient being lactose intolerant.
  3. The nurse should educate the wife about tube feeding.

Page Ref: 123

Cognitive Level:  Applying

Client Need/Sub:  Physiological Integrity : Pharmacological and Parenteral Therapies

Standards:  QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

LO & MNL LO:  LO02: Discuss enteral nutrition, including benefits, potential complications, gastric versus postpyloric feeding, and barriers to providing enteral nutrition.