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

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

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

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

MULTIPLE CHOICE

1. A affected person is having problems from stomach surgical procedure and stays NPO. As a result of enteral tube feedings aren’t attainable, the choice is to provoke parenteral feedings. What are the key problems for this remedy?

a.

Aspiration pneumonia and sepsis

b.

Sepsis and fluid and electrolyte imbalances

c.

Fluid overload and pulmonary edema

d.

Hypoglycemia and renal insufficiency

ANS: B

Due to the excessive dextrose focus, together with the fluid and electrolyte content material, the affected person is positioned at excessive danger for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a possible complication of enteral feedings; sepsis is a possible complication of parenteral vitamin. Fluid overload is feasible however unlikely and isn’t a significant complication of parenteral vitamin. Hyperglycemia is extra of a priority than hypoglycemia with parenteral vitamin; nonetheless, renal insufficiency is just not associated to parenteral vitamin.

DIF: Cognitive Stage: Keep in mind/Information REF: p. 85

OBJ: Describe methods for monitoring and evaluating the vitamin care plan.

TOP:Nursing Course of Step: Evaluation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

2. A affected person is being ventilated and has been began on enteral feedings with a nasogastric small-bore feeding tube. What’s the main purpose the nurse should continuously assess tube placement?

a.

To evaluate for paralytic ileus

b.

To keep up the patency of the feeding tube

c.

To watch for pores and skin breakdown on the nostril

d.

To stop aspiration of the feedings

ANS: D

Sufferers who’re on a ventilator and who’re receiving tube feedings are at a excessive danger for aspiration and ventilator-associated pneumonia. Evaluation of tube placement will neither decide presence of paralytic ileus nor keep patency. Evaluation of tube placement is carried out to attenuate aspiration danger, not pores and skin breakdown on the nostril.

DIF: Cognitive Stage: Keep in mind/Information REF: p. 85 | Desk 6-4

OBJ: Describe methods for monitoring and evaluating the vitamin care plan.

TOP:Nursing Course of Step: Evaluation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

3. The affected person is to start out parenteral vitamin. The nurse is aware of to arrange which website for catheter insertion?

a.

Basilic vein

b.

Femoral vein

c.

Radial artery

d.

Subclavian vein

ANS: D

Whole parenteral vitamin is run by means of a central intravenous line, such because the subclavian vein. Arteries are by no means used. The femoral website is averted. The basilic vein is just not a central website.

DIF: Cognitive Stage: Keep in mind/Information REF: p. 80

OBJ:Talk about observe pointers associated to dietary assist.

TOP:Nursing Course of Step: Implementation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

4. A affected person has been admitted to the crucial care unit after a stroke. After “failing” a swallow research, the affected person is positioned on enteral feedings. Following placement of a nasogastric tube for tube feeding, what’s the subsequent crucial step?

a.

Administer drugs.

b.

Cap off and wait 24 hours earlier than beginning feedings.

c.

Receive a chest radiograph.

d.

Begin the tube feeding.

ANS: C

Appropriate placement should be verified by radiograph earlier than use of the tube for both feeding or administering drugs. There is no such thing as a purpose to cap the tube and wait; as soon as placement is verified, the tube can be utilized.

DIF: Cognitive Stage: Apply/Utility REF: p. 86 | Desk 6-4

OBJ:Talk about observe pointers associated to dietary assist.

TOP:Nursing Course of Step: Planning

MSC: NCLEX Consumer Wants Class: Physiological Integrity

5. A critically unwell affected person has a nonhealing wound and malnutrition. Which element of dietary supplementation is most essential for this affected person to obtain?

a.

Arginine

b.

Omega-3 fatty acids

c.

Branched-chain amino acids

d.

Vitamin A

ANS: D

Vitamin A is important for wound therapeutic. Arginine can also be essential in wound therapeutic however is extra essential for trauma and septic sufferers, as are omega-3 fatty acids. Branched-chain amino acids are crucial for burdened sufferers who’ve liver dysfunction or ARDS.

DIF: Cognitive Stage: Keep in mind/Information REF: p. 82 | Desk 6-1

OBJ:Talk about observe pointers associated to dietary assist.

TOP:Nursing Course of Step: Implementation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

6. A affected person is being fed by means of a nasogastric tube positioned in his abdomen. The nurse would perform which intervention to attenuate aspiration danger?

a.

Add blue dye to the formulation.

b.

Assess the residual each hour.

c.

Elevate the pinnacle of the mattress 30 levels.

d.

Present feedings by way of steady infusion.

ANS: C

The pinnacle of the mattress must be stored elevated no less than 30 levels if attainable throughout tube feedings to attenuate reflux. Blue dye shouldn’t be used. Neither steady feedings nor checking for residual will reduce aspiration.

DIF: Cognitive Stage: Apply/Utility REF: p. 86 | Desk 6-4

OBJ:Talk about observe pointers associated to dietary assist.

TOP:Nursing Course of Step: Implementation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

7. A affected person who’s receiving steady enteral feedings has simply vomited 250 mL of milky inexperienced fluid. What motion by the nurse takes precedence?

a.

Notify the supplier.

b.

Assess the affected person’s lungs and oxygen saturation.

c.

Cease the tube feeding.

d.

Gradual the speed of the infusion.

ANS: C

Nausea and vomiting are indicators of tube feeding intolerance. The nurse ought to first cease the feeding. Then the nurse can assess for different indicators of intolerance and aspiration. After a whole evaluation, the nurse would notify the supplier.

DIF: Cognitive Stage: Apply/Utility REF: p. 85

OBJ: Describe methods for monitoring and evaluating the vitamin care plan.

TOP:Nursing Course of Step: Evaluation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

8. A affected person is receiving enteral feedings and studies fullness and stomach discomfort. What motion by the nurse is greatest?

a.

Join the feeding tube to suction.

b.

Proceed the tube feeding.

c.

Lower the tube feeding.

d.

Assess the affected person’s gastric residual.

ANS: D

The affected person is probably not tolerating the tube feeding. The nurse ought to assess the gastric residual and maintain the feeding whether it is larger than 500 mL. The opposite actions aren’t warranted; the nurse wants additional info earlier than continuing.

DIF: Cognitive Stage: Apply/Utility REF: pp. 85-86 | Desk 6-4

OBJ: Describe methods for monitoring and evaluating the vitamin care plan.

TOP:Nursing Course of Step: Implementation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

9. Along with residual abdomen quantity, what different proof suggests feeding intolerance?

a.

Belly distension

b.

Absence of tympany on percussion

c.

Energetic bowel sounds

d.

Elevated blood glucose by fingerstick

ANS: A

Belly distension is predicted if the feedings aren’t being absorbed. Tympany happens together with distension.

DIF: Cognitive Stage: Keep in mind/Information REF: pp. 85-86 | Desk 6-4

OBJ:Talk about strategies for evaluating dietary standing.

TOP:Nursing Course of Step: Evaluation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

10. Roughly 5 days after beginning tube feedings, a affected person develops excessive diarrhea. A stool specimen is collected to test for which attainable trigger?

a.

Clostridium difficile

b.

Escherichia coli

c.

Occult blood

d.

Ova and parasites

ANS: A

Sufferers receiving enteral vitamin who develop diarrhea are evaluated for antibiotic- related causes, together with Clostridium difficile.

DIF: Cognitive Stage: Keep in mind/Information REF: p. 86 | Desk 6-4

OBJ: Describe methods for monitoring and evaluating the vitamin care plan.

TOP:Nursing Course of Step: Evaluation

MSC: NCLEX Consumer Wants Class: Physiological Integrity

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