Chapter 12: Care of the Eye and Ear Perry et al.: Nursing Interventions & Clinical Skills
MULTIPLE CHOICE QUESTIONS AND ANSWERS
1. The nurse prepares to remove the patient’s soft contact lenses. Which intervention does
the nurse implement to remove the lenses without traumatizing the cornea? a. Irrigate the eye with 50 mL of a sterile saline solution.
b. Pull the lid down and instruct the patient to blink.
c. Pinch the sides of the lens together and pop it out.
d. Move the lens to the sclera and compress the lens gently.
ANS: D
To remove a soft contact lens from a patient’s eye, the nurse moves the lens to the sclera and gently compresses it. This maneuver disrupts the surface tension holding the lens to the eye, allowing the nurse to lift the lens off the eye without traumatizing the cornea. The nurse avoids flooding the eye with irrigation solution because it increases the risk of losing the lens. The nurse asks the patient to blink to eject a hard lens. The nurse avoids pinching the lens since that would risk corneal trauma.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
2. The nurse irrigates the patient’s eye after the patient splashes an irritating liquid into it.
Which intervention does the nurse implement to prevent injury during eye irrigation? a.
Positions the patient in high-Fowler’s position during the procedure.
b. Prevents the tip of the irrigating system from contacting the eyeball.N
c. Reassures the patient that the eye cannot be closed during irrigation.
d. Allows the irrigating solution to run from the outer to the inner canthus.
ANS: B
The nurse prevents additional injury to the patient’s eye during the eye irrigation by maintaining the irrigation system tip away from the eye. The nurse positions the patient in the side-lying position on the side of the affected eye to control the flow of irrigation solution. The patient is allowed to blink periodically during the irrigation. The nurse directs the irrigation solution to flow from the inner to the outer canthus to prevent contamination of the eye from a contaminated area.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing Process: Implementation
3. The nurse and the patient discuss the patient’s need for a hearing aid. What information
does the nurse include in patient teaching?
a. An in-the-ear hearing aid is easy to manipulate.
b. The patient’s specific needs and abilities are determining factors.
c. The choice of a hearing aid is basically a financial matter.
d. Behind-the-ear models are inferior to the other types.
ANS: B
The patient’s specific needs and abilities are the determining factors in selecting a model of hearing aid for use. Hearing aids are available in many styles to suit a patient’s individual needs. In-the-ear hearing aids are a poor choice for a patient with impaired manual dexterity because they are small. Behind-the-ear hearing aids are suitable for mild-to-profound hearing loss. Choosing a hearing aid is partially a financial decision, but not all models suit a patient’s needs effectively.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
4. The nursing assistive personnel (NAP) reports that the hearing-impaired patient is usually alert and oriented with the hearing aid in place, but the patient is not responding to verbal communication this morning. What action does the nurse implement first? a.
Document that the patient’s neurological status is poor.
b. Assess the patient for clinical indicators of a stroke.
c. Remove the hearing aid and clean it with a stiff brush.
d. Instruct NAP to check the hearing aid battery.
ANS: D
Because the patient is usually alert and oriented, the nurse realizes that the most likely cause
of the patient’s change in hearing is a defective hearing aid battery. The nurse directs the NAP to check the battery first because this is also a simple factor to eliminate. After checking the batteries, the nurse instructs the NAP to clean the hearing aid with the brush supplied by the manufacturer, which is the brush that the patient uses regularly. The nurse does not know yet whether the patient’s neurological status is poor. The NAP reports clinical indicators of
normal neurological function, making a stroke unlikely.
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5. The nurse instructs the patient on how to care for the hearing aid at home. What
information does the nurse include in patient teaching to prevent damage to the hearing aid?
a. Store the hearing aid with a desiccant.
b. Wash the hearing aid in hot soapy water.
c. Keep the hearing aid in the bathroom.
d. Clean the hearing aid with a pipe cleaner.
ANS: A
The nurse instructs the patient to store the hearing aid in a dry container with a desiccant to keep moisture and heat away from the device because moisture and heat can destroy the delicate electronic components of the hearing aid. The nurse instructs the patient to avoid immersing the hearing aid and inserting objects into it. The nurse also instructs the patient to avoid storing the hearing aid in the kitchen or bathroom to prevent exposure to moisture and heat.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning
6. The nurse is preparing to remove cerumen from an older adult’s ear. Nursing care is
appropriate if the nurse uses which procedure?
a. Applies slight negative pressure to the ear canal.
b. Asks the patient not to move while the ear is being irrigated.
c. Cleans the ear canal with a soft cotton swab to remove any remaining cerumen.
d. Instills cool irrigating fluid to break down the cerumen in the ear canal.
ANS: B
The nurse prepares the patient by explaining the procedure, including the need to remain still while the ear is being irrigated. To prevent damage to the tympanic membrane, negative pressure is never applied to the ear canal. The nurse avoids inserting a cotton swab into the ear canal because it is likely to push cerumen further into the ear. Cool irrigating fluid is contraindicated because it can cause nausea and vertigo.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning
7. The patient asks the nurse to irrigate both ear canals to improve hearing and comfort. The patient has bilateral brown ear drainage and a history of a right mastoidectomy and perforation of the left tympanic membrane. Which intervention by the nurse takes priority? a. Inform the patient that the ears are infected.
b. Perform an otoscopic examination of the canals.
c. Collaborate with the audiologist about a hearing aid.
d. Irrigate the ear canals with warm saline solution.
ANS: B
The nurse completes the ear assessment with an otoscopic examination of the ear canals to provide comprehensive patient data to the health care provider. The nurse wants to observe cerumen, the tympanic membrane, and origin of the drainage in both ears. He or she avoids irrigating an ear with drainage because the drainage implies that the tympanic membrane is impaired. The nurse avoids sharing a diagnostic conclusion with the patient because he or she N does not know that the ears are infected. The nurse’s scope of practice does not provide for collaboration with the audiologist about the need for a hearing aid. This is done by the health care provider after a thorough assessment to determine the patient’s plan of care and therapeutic regimen.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Planning
8. The nurse assesses a 3-year-old patient with a dried bean in the left ear canal. Which action does the nurse implement?
a. Wait for the bean to fall out.
b. Examine the ears with an otoscope.
c. Collaborate with the health care provider.
d. Irrigate the ear to flush out the bean.
ANS: C
The nurse inspects the ears visually without the aid of an otoscope to complete the nursing assessment and then collaborates with the health care provider to remove the bean. The bean is not likely to fall out because it is more likely to increase in size by being in the moist environment of the ear canal. The nurse avoids an otoscopic examination because inserting the otoscope into the ear canal is likely to affect the bean and make it harder to remove. The
nurse avoids irrigating the patient’s ear canal because the positive pressure from the irrigation solution is likely to affect the bean and make it harder to remove. In addition, a dried bean
will absorb water, and its size will increase, further aggravating its removal.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
9. The nurse irrigates the patient’s right ear with saline solution to improve hearing. Which patient symptom requires immediate nursing intervention? a. Patient hearing acuity remains stable.
b. Patient senses that irrigant is slightly warm.
c. Patient complains of nausea and vertigo.
d. Patient drainage contains brown particles.
ANS: C
The nurse expects to irrigate the patient’s ear canal without causing patient discomfort, pain, nausea, or vertigo by warming the irrigation solution before instilling it. The nurse expects the patient to sense the warmth of the irrigation solution; this is an expected outcome. Irrigation drainage from the ear containing brown particles is consistent with clinical indicators for effective ear irrigation because this is evidence of cerumen removal; this is an expected
finding if cerumen was in the ear canal before the procedure. Failure of patient hearing to improve after irrigation is a possible unexpected outcome, but it is not influenced by warming
N of solution.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
10. The nurse is instructing a patient on the procedure to remove a hard contact lens.
Instruction by the nurse is correct if the patient uses which technique? a. Slides lens onto the sclera and pinches off the lens.
b. Draws periorbital skin taut and asks the patient to blink.
c. Uses a bulb syringe and applies suction to the lens.
d. Squeezes the upper and lower lids together to pinch the lens.
ANS: B To remove a hard lens from a patient’s eye, the nurse draws the skin surrounding the eye tightly and instructs the patient to blink. Pulling the skin creates mild tension, which the eyelid uses to dislodge the lens from the cornea. Sliding a contact lens onto the sclera and pinching off the lens is the procedure to remove a soft contact lens. To prevent a corneal abrasion, the nurse avoids using suction to remove a contact lens. He or she avoids squeezing the eyelids together to prevent eye and conjunctival trauma from the hard lens.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Evaluation
11. After removing a soft contact lens, the nurse observes that the sides of the lens are sticking together. Which intervention will the nurse implement before storing or reinserting the lens? a. Thoroughly soak the lens in saline solution.
b. Rub the contact lens briskly to remove the debris.
c. Pry the lens apart gently with a fingertip.
d. Use the cleaning solution on the lens; then replace or store it.
ANS: A
A soft contact lens sticks together because it is dry. The nurse rehydrates the lens with saline solution; and the lens becomes soft, supple, less sticky, and suitable for the patient to wear or to store. Hard and soft contact lenses should never be rubbed because rubbing is likely to damage the lens. The nurse avoids prying apart the lens to prevent lens damage. Cleaning solution for lenses is intended to remove residue and debris from the lens but is not intended as a source of lens hydration. After using the cleaning solution, the nurse rinses the lens in saline solution before storage or reinsertion.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
12. The nurse admits a patient who wears a hearing aid for surgery. Which method does the nurse use to assess the patient’s hearing acuity with the hearing aid in place? a. Whisper very softly behind the patient.
b. Cover the patient’s unaffected ear before talking.
c. Send the hearing aid to the audiologist for analysis.
d. Check patient response using a normal voice level.
ANS: D
The nurse needs to determine the patient’s hearing ability with the hearing aid in place and N
both ears available to hear. The nurse speaks with the patient in a normal tone of voice, assesses the patient’s ability to respond properly, and asks the patient whether this is baseline hearing acuity. If the patient has difficulty hearing the nurse with normal conversation, the nurse conducts a more detailed assessment and ensures that the hearing aid battery is good. The nurse performs the assessment before surgery to alert the surgical team to the patient with a sensory impairment so an alternative method of communication may be identified. Whispering is a hearing acuity test used to evaluate a patient without hearing aids. The nurse avoids sending the hearing aid to an audiologist because the nurse is able to determine
whether the patient can hear.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Assessment
13. Which is the priority nursing diagnosis for a patient with altered sensory perception? a.
At risk for injury
b. Deficient knowledge
c. Impaired communication
d. Impaired social interaction
ANS: A
The patient with a sensory impairment is at high risk for injury because many methods of communication with the patient cannot be used or need alteration to accommodate the impairment. The sensory impairment may render the patient unable to follow important directions, visualize hazards, or provide information to the health care team. However, the nurse’s priority is to maintain safety first and then to manage the communication impairment to prevent injury effectively. Deficient knowledge is a suitable nursing diagnosis for the patient who has a sensory impairment in acute care because the patient is likely to miss important information and is unaware of potential solutions to the problem. The patient with a sensory impairment frequently has impaired social interaction, so this is a reasonable nursing diagnosis. However, safety is always more important than psychosocial issues.
DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Diagnosis
14. The family of an older adult brings the patient to the health care provider because the patient seems to be confused or depressed at times. What approach by the nurse can best obtain valuable information about the underlying problem?
a. Talk to the patient in a normal voice while standing away from him or her.
b. Whisper questions to the patient to determine if the questions can be understood.
c. Ask the family to explain the activity patterns of the patient.
d. Ask the family for a list of what the patient usually eats.
ANS: A
The nurse can determine if the patient has a hearing impairment by standing a distance from him or her and speaking in a normal tone of voice. Hearing loss can cause the patient to be depressed or seem to be confused. The focus of the assessment needs to be on the patient, not
the family. Whispering is inappropriate because this is not a level at which communication N
usually occurs. The patient’s activity level can be affected by many things other than hearing.
The dietary pattern of the patient is not important at this time.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Assessment
MULTIPLE RESPONSE
1. The nurse plans care for a patient who has a hearing deficit. What actions when taken by the nurse indicate a good understanding of appropriate care? (Select all that apply.) a. Face the patient before beginning to speak.
b. Keep the lights dimmed low.
c. Speak in a slow, clear, and loud voice.
d. Eliminate external voices.
e. Do not talk over the patient.
ANS: A, D, E
When patients have a hearing deficit, be sure they understand what you communicate to them. Always face the patient before beginning to speak and make sure there is enough light for the patient to see your lips. Eliminate external noises; speak in a slow, clear, normal tone of voice.
Do not speak in a loud voice. Ask patients what communication styles they prefer. Never talk over or exclude a patient from conversation or decisions.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Planning
2. The nurse is orienting a new graduate nurse about eye irrigation. Which statement indicates a good level of understanding of the procedure? (Select all that apply.) a. “I should irrigate from inner to outer canthus.”
b. “I should tell the patient not to blink.”
c. “I should always remove the contact lenses first.”
d. “I should hold the lids open by putting gentle pressure to the lower bony orbit.”
e. “I should irrigate until clear or prescribed amount of time is reached.”
ANS: A, D, E
The eye is irrigated from the inner to outer canthus. The patient is allowed to blink periodically, which can help move secretions from the upper conjunctival sac. You should determine if the patient is wearing contact lenses. Do not remove contact lenses unless there is a rapid swelling, there is a chemical injury, or you cannot get rapid medical attention. You can remove them later if they do not flush out during irrigation. Continue irrigation with
prescribed solution, volume, or time or until secretions are cleared.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
3. The nurse is performing eye care for a comatose patient. Which interventions indicate the nurse has a good understanding of the appropriate care needed? (Select all that apply.) a. The nurse cleans the eye with water or saline.
b. The nurse uses an eyedropper to instill the prescribed lubricant.
c. The nurse wipes away excess lubricant moving from outer canthus to inner canthus. N
d. The nurse applies eye patches when the blink reflex is absent.
e. The nurse changes the eye patches every 8 hours.
ANS: A, B, D
To prevent damage to corneas in a comatose patient, eye care is performed. The nurse cleans the eyes with water or saline, wiping from inner canthus to outer canthus, using a separate washcloth or cotton ball for each eye. Lubricant is applied using an eyedropper, wiping excess from inner canthus to outer canthus. Eye patches are used when there is no blink reflex and
are changed every 4 hours.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
4. The nurse is assessing an elderly patient’s ability to understand how to properly care for a new hearing aid. Which of the following statements indicate further education is needed? (Select all that apply.)
a. “I can wear my hearing aid in the shower.”
b. “I should take it out when I go to the pool to swim.”
c. “I can wear my hearing aid when I get my hair done.”
d. “I need to make sure I don’t leave them in a hot car.”
e. “I should store the batteries in a dry, safe place.”
ANS: A, C
Patients should be instructed to avoid exposure of hearing aids to extreme heat, cold, or moisture. Do not leave in case near stove, heater, or sunny window. Do not use with hair dryer on hot settings or with sunlamp. Do not wear when bathing, during excess sweating, or when shampooing at a hair stylist. Do not use hair spray or other hair-care products while
wearing hearing aids. Store batteries in a dry, safe place away from pets and children. Always
keep a set of unused batteries in the home.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
N
Chapter 13: Promoting Nutrition Perry et al.: Nursing Interventions & Clinical Skills
MULTIPLE CHOICE
1. 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.
ANS: B
The nurse maintains and enhances the patient’s self-esteem by encouraging the patient with positive reinforcement, acknowledging the patient’s progress with self-feeding, and engaging him or her in conversation during feeding. Feeding the patient may reinforce feelings of inadequacy, worthlessness, or embarrassment. Taking food by straw may be contraindicated and increase the risk of aspiration, depending on the patient’s neuromuscular coordination for chewing and swallowing. The speech therapist can contribute to the patient’s nutritional status with specific feeding techniques, but this is not related to self-esteem.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
2. 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.N
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.
ANS: D
The nurse gathers additional information by using the nursing process to prevent malnutrition for a new patient in the long-term care facility. Identifying barriers to nutrition begins with obtaining objective and subjective data by which the nurse gathers valuable nutritional information, including muscle function, teeth, cognition, and patient food preferences. Requesting a diet change is premature and not based on assessment data. Asking the daughter for information reveals the daughter’s opinion, anecdotal information, and possibly biased observations about the patient. The use of the word “why” is also not therapeutic. Reminding the patient about nutrition may be a useless intervention if his or her cognition is low, if he or she has a sensory or communication disorder, or if he or she is depressed. In addition, the patient can interpret this as an insult to his or her intelligence.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
3. 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.
ANS: B
The nurse plans an adequate amount of time for patient feeding to address complications from impaired swallowing. With nursing supervision and encouragement and in a relaxed manner, the food is prepared properly; the patient chews food thoroughly, swallows as necessary, and takes short breaks while eating. Clear liquids may be contraindicated for the patient.
Thickener may need to be added, depending on the patient’s status. Family coaching may pressure, misdirect, or shame the patient; increase the risk of aspiration or choking; and decrease the patient’s appetite. Low-Fowler’s position is contraindicated for swallowing difficulties and feeding because an upright position facilitates swallowing.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Planning
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.
ANS: D
A suitable outcome for a patient with impaired swallowing is that the lungs remain clear after eating, which indicates that the patient did not aspirate. A stable weight over 3 days indicates that the patient is ingesting and absorbing sufficient nutrients to avoid weight loss, which is also indicative of goal outcome. However, an intact airway and lack of aspiration and N respiratory complications take priority. Holding amounts of food in the pockets of the mouth indicates difficultly moving the food for chewing and swallowing. Movement of the larynx normally occurs during swallowing.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
5. 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.
ANS: A
The nurse suctions the oropharynx of a patient with dysphagia who chokes while eating to maintain the airway, the highest priority on the patient’s hierarchy of needs. A positioning change is not indicated unless the patient starts to vomit or becomes unresponsive; then the nurse places the patient in the recovery position. The nurse should not leave the patient until
the choking is resolved and the patient is stabilized. The patient should not take deep breaths, which may draw in food and aggravate choking.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. 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.
ANS: B
The nurse assesses the patient for altered taste perception because the acuity of several senses deteriorates with aging, including the senses of taste and smell; these sensory functions are important for food enjoyment and appetite. To promote health and well-being, the nurse recognizes that the patient is at risk for malnutrition and assesses him or her to gather data for planning care because well-nourished patients are more likely to have positive health outcomes. Serving food at room temperature is an intervention but is not likely to be entirely helpful since it may or may not be the problem. The nurse should find out more information through assessment and then plan appropriately. Eating with a friend can make eating more enjoyable, but, if a physiological reason exists, the reason needs to be addressed first. Serving bland foods is not appropriate at this time. If there is an alteration in ability to taste and smell, bland foods might not be most appetizing to the patient.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Assessment
7. 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.N
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.
ANS: D
To best facilitate patient learning, the nurse provides verbal instructions while demonstrating feeding techniques to explain each step, provide insight, and clarify directions. This also allows the nurse to assist the patient with eating as needed. Depending on the nature of the
injury, the hand tremors can be permanent; so the patient needs to learn self-feeding with hand
tremors. Showing a video may be an appropriate intervention, however; this alone is not optimal for teaching and answering questions. All required equipment for self-feeding should be provided to determine which is best for the patient because self-feeding with inadequate equipment can set up the patient for failure. In addition, some pieces of equipment such as a knife and fork are meant to be used simultaneously as needed.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
8. 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
ANS: A
The nurse should avoid pork chops. Jewish people who follow the kosher diet are prohibited from eating pork, predatory fowl, shellfish, blood, and meat mixed with dairy products.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
9. 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
ANS: D
The patient practicing Orthodox Judaism cannot eat shellfish; so the nurse eliminates lobster from the patient’s dietary plan. Orthodox Jewish dietary guidelines do not restrict dietary intake of dairy products except that dairy products are not mixed with meat. The patient’s religious practices allow caffeine in the diet. Caffeine is not prohibited.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
10. The nurse assists the patient who had a recent cerebral vascular accident (CVA or stroke)
with N 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.
ANS: B
The patient’s priority needs, in order, are airway, breathing, and circulation (ABCs), so the nurse’s priority action is to maintain the airway. To accomplish this, the nurse suctions the patient to prevent an airway obstruction. After the airway is clear, the nurse can provide supplemental oxygen as prescribed if the patient continues to have difficulty or has oxygen desaturation from choking. If the patient continues to have difficulty, the nurse should call for help to obtain emergency equipment. The nurse can place the patient in the recovery position after choking if the patient loses consciousness, continues to choke, or starts to retch or vomit. Reclining the patient is contraindicated because it increases the risk of aspiration.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
11. 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
ANS: B
Pale conjunctivae are a clinical indicator of a nutritional deficit consistent with a low serum hemoglobin or hematocrit. The hematological deficiencies result in a low oxygen-carrying capacity and a deficient number of red blood cells in the blood. This decreases the ability of the erythrocytes to oxygenate the tissues adequately, thereby resulting in pale mucous membranes. Conjunctivae should appear reddish pink. Long, shiny hair and pink oral mucosa are clinical indicators of a patient who consumes an adequate diet. Nails are normally firm and pink.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
12. 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.
ANS: D
Reddish-pink oral and conjunctival mucous membranes are indications of a well-nourished person because this color is consistent with well-oxygenated tissue resulting from adequate amounts of hemoglobin and erythrocytes. A malnourished person is likely to have pale
mucous membranes because the individual does not receive adequate nutrition in the diet to N provide the body with the necessary iron to synthesize hemoglobin, amino acids to manufacture protein, and other nutrients to manufacture red blood cells in adequate amounts. The tongue is a vivid pink or deep red, with papillae present in adequately nourished individuals. Generally consuming 80% of meals is an acceptable dietary intake; however, a malnourished person usually needs to eat the entire meal on a consistent basis to restore and maintain health and wellness. An intact sense of taste is helpful in maintaining nutrition, but does not indicate if the patient is well-nourished or not.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
13. 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
ANS: B
Pancakes with sliced bananas are a suitable food choice for patients on a mechanical soft diet because this diet requires foods that are very easy to chew, require minimal chewing, or allow the patient to eat without teeth. Scrambled eggs are appropriate, but not the bacon. Toast requires chewing, which is unacceptable on the mechanical soft diet. Strained soups and custard are on the full liquid diet.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
14. 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
ANS: C
Cranberry juice is a suitable choice for a patient on a clear liquid diet because this product is made with juice, flavored water, and possibly a sweetener. It is possible to actually see through the liquid. Orange juice, vegetable juice, and ice cream are all dense liquids that the nurse cannot see through. They are suitable for a full liquid diet.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
15. 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.N
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.
ANS: C
Taking a long time may indicate trouble initiating a swallow. This is a symptom of oropharyngeal dysphasia. Until the nurse assesses the patient for dysphagia, consults with other members of the health care team, and collaborates on a plan of care, he or she must assume responsibility for the patient’s aspiration precautions. The nurse instructs the NAP to observe for choking and coughing after mealtime is over. The NAP may be instructed to assist the patient who refuses most meals by encouraging the patient, avoiding coercion to get the patient to eat, and reporting the amount of food eaten by the patient. With training and instruction, the NAP would also be able to assist the patient learning how to use adaptive utensils. The NAP is able to assist the postoperative patient with ice chips.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Assessment
16. 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
ANS: D
Food on a soft diet must be low in fiber, easily digested, and easy to chew; thus thin spaghetti with tomato sauce is suitable. A soft diet is slightly different from a mechanical soft diet because soft-diet foods must be low in fiber and mechanically soft foods can contain fiber that are pureed or ground. The oatmeal is rich in fiber and is considered a high-fiber food. Fruits and vegetables need to be canned or cooked. The tuna salad has the mayonnaise, which provides quite a bit of fat. The meat must be chewed and is not easily digested.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
17. 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.
ANS: A
To start a community nutrition program, the nurse applies the nursing process and implements the first step, assessment and data gathering, to determine community needs. The nurse
gathers suitable data for planning the program by screening older people for malnutrition and people at risk for malnutrition using a nutritional screening tool. The nurse analyzes the data, including height, weight, and health history to tailor the overall program; organizes suitable resources; plans for individual nutritional assistance; and matches people who are N malnourished or at risk with community resources such as food banks, free meals, and Meals on Wheels. The remaining choices do not help the nurse identify people at risk for malnutrition. Teaching about a balanced diet is a prevention technique, and obtaining free vitamins and providing contact information may help people find community resources but doesn’t identify their risk levels.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
18. 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.
ANS: B
The nurse instructs the NAP to cut a 10.2-cm (4-inch) strip of adhesive tape to secure the feeding tube to the patient’s nose while the nurse supervises the NAP’s action. Icing a feeding tube is never recommended because it would only make the tube stiffer and harder to insert. The nurse is responsible for patient assessment before tube insertion because it requires clinical judgment and critical thinking. The guidewire remains in the feeding tube until placement is confirmed with an x-ray film.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
19. 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
ANS: A
The nurse has the patient swallow water during tube placement to help pull the tube into the correct position. The water also serves as a lubricant. It is expected that the patient will swallow without difficulty to facilitate tube passage through the esophagus and not coil up in the oropharynx. Auscultating for placement would be done after the procedure but is not the recommended procedure to determine placement as it is unreliable.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
20. 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.
N
ANS: A
The nurse attempts to insert the feeding tube and stylet into the opposite naris after encountering difficulty in the first naris because a physical obstruction is the most likely cause of the problem. The nurse avoids advancing the stylet if the feeding tube does not cover it because the unguarded stylet is likely to cause tissue trauma to the patient’s nasal
passageways or oropharynx. Once the stylet is removed from the feeding tube, it cannot be
reinserted without damaging the tube. Using a second stylet is contraindicated for tube manipulation.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
21. 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.
ANS: A
The nurse inserts a gastric feeding tube and expects to confirm tube placement in the stomach;
the nurse verifies gastric placement by measuring the pH of the aspirate and expects it to be
5.0 or less because hydrochloric acid from gastric parietal cells acidify gastric contents. Feeding tube aspirate of 7.0 is most likely from the intestines. A gastric feeding tube is above the pyloric sphincter, the sphincter that controls gastric emptying into the duodenum. The cardiac sphincter is above the area where a pH sample could be obtained.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
22. 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.
ANS: D
The nurse stops the tube feeding and collaborates with the health care provider after assessing a patient who receives a continuous tube feeding with no evidence of peristalsis. Without peristalsis, the formula accumulates in the stomach, and eventually the patient can vomit, increasing the risk of aspiration. This finding may also indicate an obstruction or other problem that would contraindicate the feeding. The nurse should document that bowel sounds are absent, but this is not a priority over consulting with the provider. Any patient receiving tube feedings receives nursing assessments for diarrhea and constipation; in addition, if the
patient has diarrhea, bowel sounds are likely to be loud, frequent, and high pitched.N DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
23. 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.
ANS: D
The nurse expects to aspirate no residual volume from the patient who receives intermittent intestinal tube feedings because the small-intestines are unable to sequester fluid. The placement of this type of tube is verified by x-ray film; and, if nothing is aspirated afterward, it is assumed that placement of the tube is correct.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Planning
24. 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.
ANS: A
Tube feedings infused into the stomach or intestines bypass food warming that takes place as food passes through the mouth and esophagus; thus the nurse instructs the patient to infuse the formula at room temperature to avoid abdominal cramping. The patient should report diarrhea or constipation to the health care provider before implementing additional fluids since these may be indications of other complications of tube feedings. Flushing with 500 mL of water after each tube feeding is excessive and risks causing fluid volume overload in the patient and can raise the risk of vomiting and aspiration. Because nasointestinal feedings generally infuse continuously, the nurse instructs the patient to replace the feeding bag and tubing every 24 hours and flush the tubing before and after each new infusion. The nurse instructs the patient
to infuse the same can of formula for up to 8 hours without adding formula over the infusion
period.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
25. 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.
ANS: D N
The nurse checks tube placement and administers medication with a 60-mL syringe. The feeding tube bag is changed every 24 hours to prevent bacteria buildup in the system. The maximum time that formula can hang in an open system is 8 hours. The 10-mL syringe would cause excessive positive pressure into the feeding tube. Placement is checked using a 60-mL syringe.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
26. 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.
ANS: D
The nurse plans follow-up nursing interventions after aspirating pale and straw-colored fluid because intestinal aspirate should be green, indicative of the bile concentration of the fluid. Because the aspirate is inconsistent with clinical indicators for intestinal fluid, the nurse investigates further to verify tube placement before instilling anything into the nasointestinal tube. The nurse expects to aspirate a small amount of greenish fluid indicative of bile in the fluid. This also indicates placement of the nasointestinal tube in the intestines because the intestines cannot hold large amounts of fluid as the stomach can. The nasointestinal tube is expected to collapse with negative pressure because it is a soft pliable tube. A small amount of formula aspirated is not a problem and does not require follow-up. It is acceptable.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Evaluation
27. 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.
ANS: D
The nurse instructs the patient to report a pH less than 6.0 of the intestinal aspirate because this fluid should be alkaline and have a pH greater than 6.0 from exposure to intestinal fluid and bile. If a patient who is able to competently handle administering a nasointestinal feeding at home aspirates and obtains no fluid, the nurse assumes that the infusion is operating without difficulty because no aspirate is an expected finding. The nurse avoids instructing the patient to instill air to verify tube placement; however, he or she instructs the patient to instill
N 30 mL of air before aspirating gastric fluid to displace the fluid and facilitate aspiration. Tube feeding formula should be at room temperature to avoid abdominal cramping.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
28. 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.
ANS: B
A clinical indicator of a successful therapeutic regimen in this patient is a residual volume below 100 mL. This indicates the stomach is emptying gastric contents into the duodenum and precipitating intestinal peristalsis. The peristaltic action moves the formula through the gastrointestinal tract to prevent formula accumulation in the stomach. Tachypnea in a patient with gastric tube feedings warrants further investigation by the nurse because tachypnea is
consistent with clinical indicators for aspiration. A stable weight over one month is consistent with delivering inadequate calories. The patient should be gaining weight. The nurse expects urine output between 30 and 50 mL/hr, depending on the patient; however, this is not related to a successful feeding regime.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
29. 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
ANS: D
The nurse allows the intermittent tube feeding to infuse over 30–45 minutes by gravity to reduce the risk of abdominal discomfort, vomiting, or diarrhea induced by bolus or excessively rapid formula infusions. Infusions of 8 or 24 hours defeat the purpose of an intermittent infusion because the therapy is mimicking normal eating patterns. Infusions of
10–15 minutes are too rapid and increase the risk of aspiration.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
30. 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.N ANS: A
Best evidence suggests that a single high gastric volume residual GRV should be monitored
for the following hour, but enteral feeding should not be stopped or withheld for an isolated high GRV, so the nurse returns the 150-mL aspirate, documents the event, and communicates the finding to the next nurse. If on several occasions the nurse aspirates more than 150 mL, the nurse notifies the provider. Excessive NGT aspirate warrants further investigation by the nurse at that time and requires the nurse to assess the patient carefully on restarting the feeding. The nurse flushes the NGT after discarding the excessive NGT aspirate to maintain tube patency. The nurse returns the aspirate if the volume is less than 200 mL. There is no reason to contact the provider at this point.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Planning
31. 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 ANS: C
The nurse expects to instill at least 120 mL of fluid to administer three medications by NGT because he or she flushes the tube with 30 mL of water before and after each medication, resulting in four flushes or 120 mL.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
32. 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
ANS: D
The nurse collaborates with the provider before initiating tube feedings for a patient without bowel sounds because any formula infused is likely to accumulate in the stomach and greatly increase the patient’s risk of aspiration. Even so, peristalsis is normally stimulated as food accumulates in the stomach, activates stretch receptors, and stimulates peristalsis in the small- and large intestines. Indications for NGT feedings exist for patients with and without a gag reflex. The nurse attempts NGT insertion into the left nostril when the right nostril is
occluded. Patients with impaired swallowing are suitable candidates for NGT feedings.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Planning
33. 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.
ANS: A
The nurse instructs the patient to swallow while the tube advances because the coordinated muscular action of the esophagus helps to direct it down through the cardiac sphincter and into the stomach. The nurse can provide patient teaching after the tube insertion because instruction provided before the insertion is unlikely to be retained. Briefly immersing the end of the tube in warm water eases insertion by softening the end of the tube for passage through
the nasal passageway. The nurse measures the length of the nasogastric tube properly by measuring from the tip of the nose to the earlobe to the xiphoid process.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
34. 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.
ANS: B
The nurse maintains the guidewire in place until intestinal placement is verified because, once it is removed, it cannot be reinserted. If the tube needs repositioning, the nurse cannot manipulate it effectively. The nurse measures from the tip of the nose to the earlobe to the xiphoid process and adds 20–30 cm for a proper length. Positioning the patient on the left or right side does not facilitate migration of the tube into the intestines. The nurse anchors the nasointestinal tube in place after placement in the jejunum is verified.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
35. 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
ANS: C
Gastric ileus, or gastroparesis, is a contraindication to nasogastric tube feedings because infused formula into the stomach is likely to remain in the stomach and accumulate. This increases the risk of aspiration and endangers the patient’s airway. The duty the nurse owes the patient is to withhold a tube feeding until bowel sounds are present. Pancreatitis, sepsis, and head trauma are indications for tube feedings as long as the patient has peristaltic action.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
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.
ANS: D
For a continuous tube feeding, the nurse attaches the feeding bag tubing to the proximal end of the NIT to begin the infusion and connects the tubing through the infusion pump. Cold formula can cause cramping. Formula should be administered at room temperature. A continuous infusion infuses around-the-clock; if the feeding is an intermittent infusion, the nurse administers it over 30–60 minutes. The nurse administers a continuous infusion with a feeding bag; intermittent infusions can be administered with a syringe.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Planning
MULTIPLE RESPONSE
1. 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.
ANS: B, D
The nurse instructs the caregiver to cap the feeding tube for an airtight seal between feedings to prevent the contents of the tube from drying and occluding the tube. Flushing a feeding tube too frequently is associated with tube occlusion. The nurse confirms tube placement before infusing the formula. The nurse instructs the caregiver to refrigerate opened cans of formula. Bacteria grows at room temperature once the cans are opened, spoiling the formula.
The patient receiving home enteral nutrition should be weighed daily or weekly, depending on
the patient’s condition.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning
2. 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.
ANS: C, D
The site should be cleansed with soap and water and assessed for excoriation, drainage, infection, or bleeding. The nurse should apply a barrier protective cream if ordered. The dressing goes over the external bar. Placing it under the bar can cause tissue erosion. Sterile gloves are not required; clean gloves are used.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
Chapter 14: Parenteral Nutrition Perry et al.: Nursing Interventions & Clinical Skills
MULTIPLE CHOICE
1. The nursing assistive personnel (NAP) reports that a patient receiving parenteral nutrition via a central line is coughing and short of breath. Which action by the nurse is the priority? a. Clamp the IV tubing.
b. Call for a chest x-ray.
c. Notify the provider.
d. Check a bedside glucose.
ANS: A
This patient has manifestations of an air embolus. The nurse would first clamp the IV tubing to prevent more air from entering the tube. The nurse will notify the provider and perhaps call for a chest x-ray, but the priority is to stop the problem. A bedside glucose is not warranted.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
2. A nursing student is teaching a patient about lab testing that will be done frequently while the patient is on parenteral nutrition. Which statement by the student requires the registered nurse to intervene?
a. “Your copper and zinc levels may change rapidly.”
b. “We will check your protein levels about weekly.”
c. “The staff will check your blood glucose frequently at first.”
d. “Your white blood cell count can help us assess for infection.”N
ANS: A
Trace elements such as copper and zinc are usually tested monthly or biannually because they do not fluctuate rapidly. The nurse would intervene to correct the student. The other statements are accurate.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
3. A patient has been receiving parenteral nutrition (PN) via a central line that has now
occluded. The patient also has a midline catheter. What modification of the PN does the nurse ensure prior to switching the PN to the midline catheter? a. Holding the lipid infusion
b. Ensuring osmolality is less than 900 mOsm
c. Doubling the insulin concentration
d. Cutting the total fluid volume to 1500 mL
ANS: B
PN formulations with an osmolality of greater than 900 mOsm should not be infused through midline, peripheral, or midclavicular lines due to the increased risk of phlebitis. Lipids can run through a midline catheter. There is no reason to double the insulin. Peripheral PN is usually delivered in a higher fluid volume than TPN, of about 2000–3000 mL.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
4. The nurse delegates some care activities to nursing assistive personnel (NAP). What action by the NAP requires immediate intervention by the registered nurse?
a. Performs fingerstick blood glucose monitoring and records results.
b. Reports shortness of breath or headaches right away.
c. Turns the alarming IV pump off and calls for the nurse.
d. Informs the nurse promptly of any changes in vital signs.
ANS: C
Adjusting the IV pump in any way is beyond the scope of practice for a NAP, so the nurse would intervene immediately if this happened. The other actions are appropriate.
DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment TOP: Nursing
Process: Implementation
5. The nurse is evaluating goals for a patient who has been on home parenteral nutrition for a month. What finding indicates that a priority goal has been met? a. Weight has increased by 5 pounds (2.26 kg).
b. Patient describes correct care of system.
c. Exit site is free of redness, tenderness, or drainage.
d. Fingerstick glucose readings are out of range only 20% of the time.
ANS: C
Patients on long-term PN are at risk for infections and sepsis. The site being free of signs of infection is a met outcome for a priority goal. The patient describing correct care is also a good outcome but not the priority. Weight should increase by 0.5N –1.5 kg or 1–3 pounds each week, so this gain is below standards. Glucose readings ideally stay within range.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
6. A patient is receiving parenteral nutrition through a multi-lumen central venous catheter.
What intervention is most important related to this patient’s situation? a. Verify patient using two unique identifiers.
b. Label each line of the tubing carefully.
c. Wipe the end port of the tubing with alcohol.
d. Check solution for particulates or discoloration.
ANS: B
The line used for PN should not be used for any other purpose. Clearly labeling each line of the tubing helps prevent errors. The other actions are appropriate for any patient on PN.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
7. The lab calls the charge nurse and reports a blood glucose reading of 220 mg/dL for a patient on parenteral nutrition via a central line. What action does the charge nurse take first? a. Notify the provider and request sliding scale insulin.
b. Inform the patient’s nurse about the need for an insulin drip.
c. Asks the pharmacy to dilute the glucose concentration.
d. Determine if the nurse drawing the blood follow protocol.
ANS: D
If the blood was drawn while the PN was infusing, or if the nurse who drew the blood did not follow the proper procedure (such as discarding the first syringe of blood), glucose readings can be artificially high. The charge nurse would first verify the process the nurse used before contacting the provider. The patient does not need an insulin drip for a glucose of 220. The charge nurse does not ask the pharmacy to dilute the glucose concentration; rather he or she anticipates sliding scale insulin being ordered. However, before requesting the insulin, the charge nurse ensures the reading is accurate.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: Implementation
8. A provider has listed orders for Peripheral Parenteral Nutrition with lipids for four patients. Which patient will the nurse clarify the orders about? a. 80-year-old on dialysis
b. 18-year-old with anorexia nervosa
c. 75-year-old with a bowel obstruction
d. 35-year-old undergoing chemotherapy
ANS: A
PPN is delivered in high fluid volumes, so patients with cardiac or renal problems may not be able to tolerate it. The nurse should verify the orders for the older patient on dialysis. The other patients are appropriate candidates.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity TOP: Nursing
Process: ImplementationN
9. A faculty member is evaluating the student’s performance when hanging a bag of Total Parenteral Nutrition. Which step indicates the student has completed the third check for accuracy?
a. Checks the bag label with the medication record at the bedside.
b. Reviews the chart to determine if the order has been entered in the system.
c. Verifies that the bag of TPN is the same that is on the medication record.
d. Reviews information on bag of TPN with pharmacist when delivered.
ANS: A
The third and final check for medication accuracy includes checking the bag label with the medication record and identifying the patient at the bedside.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
10. A nurse is preparing to discharge a patient who is going home on Total Peripheral Nutrition (TPN). What action by the nurse is most helpful in ensuring positive outcomes for the patient? a. Refer the patient to a home nutrition therapy team.
b. Order three months’ worth of supplies for the patient.
c. Assess the patient’s psychological response to the therapy.
d. Determine if any family members are willing to help.
ANS: A
Patients on home TPN benefit greatly from the services provided by a home nutrition therapy team. Three months’ worth of supplies may be too much and might end up being wasteful. Assessing the patient’s psychological response to therapy is important, but not as important as ensuring the patient has a nutrition team for support. Family members may or may not be willing to help, but the patient may not need their assistance.
DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
1. The faculty member describes conditions that indicate a need for parenteral nutrition to nursing students. Which conditions does the faculty member include? (Select all that apply.) a. Abdominal trauma
b. Severe pancreatitis
c. Short-term bowel rest
d. Poor appetite with malnutrition
e. Serious malabsorption
ANS: A, B, E
Some indications for parenteral nutrition (PN) include abdominal trauma, severe pancreatitis, and severe malabsorption. Parenteral nutrition is not used for short-term support (less than 14 days). Nurses should collaborate with the patient, family, and interdisciplinary team to promote the patient’s appetite and eating before turning to PN.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Integrated Process: Teaching-Learning
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