CH 27 Nutritional Therapy and Assisted Feeding

Before any nutritional tray is delivered to a patient, the nurse has the responsibility of:

1. determining if the patient needs assistance to eat.

2. confirming the diet on the tray with the diet sheet.

3. evaluating if the food is of the appropriate temperature.

4. adding extra salt and sugar packets.

ANS: B

The nutritional tray should be checked against the nutritional order to be sure that the patient receives the proper nutritional. No matter who actually delivers the tray, it is the nurse who confirms the accuracy of the diet.

DIF: Cognitive Level: Comprehension

REF: p. 485|Skill 27-1

OBJ: Theory #1 TOP: Nurse Role

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nutritional documentation that is most informative is:

1. ate all of lunch.

2. ate 50% of lunch without difficulty. Refused all solid food.

3. drank most of liquids without difficulty.

4. assisted feeding liquid diet, choked frequently.

ANS: B

Nutritional documentation should include percentage of intake and how it is tolerated.

DIF: Cognitive Level: Application

REF: p. 485|Skill 27-1

OBJ: Theory #1 TOP: Nutrition Documentation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

When assisting a patient with a severe visual impairment who wishes to feed himself, the nurse could best facilitate the patient's eating by:

1. placing the plate on his lap.

2. seating the patient in a chair and placing over-the-bed table appropriately.

3. orienting the patient to the position of foods on the plate using a clock face description.

4. placing each food in a separate container or bowl.

ANS: C

It is best to orient a visually impaired patient to the position of the foods on the plate by describing the plate as if it is a clock face (3 o'clock, 6 o'clock, and so on).

DIF: Cognitive Level: Application

REF: p. 485|Skill 27-1

OBJ: Theory #1

TOP: Assisting Patient with Eating

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Basic Care and Comfort

A patient who underwent surgery has an order to begin a clear liquid diet and can be offered:

1. tea with milk.

2. Jell O.

3. cream soup.

4. fruit sherbet.

ANS: B

A clear liquid diet consists of foods that are liquid at room temperature and are clear, have a low residue, and are easily digested. Gelatins are part of a clear liquid diet.

DIF: Cognitive Level: Comprehension REF: p. 488|Box 27-1

OBJ: Theory #2 TOP: Diet for Postoperative Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse caring for a patient with bulimia nervosa should add to the care plan to assess for:

1. hiding food in napkins or under plate.

2. inducing self to vomit.

3. refusing to eat.

4. flushing food down commode.

ANS: B

With bulimia nervosa, along with binge eating, there is purging, fasting, and the use of laxatives. These patients may eat everything on their tray then purge by inducing themselves to vomit.

DIF: Cognitive Level: Comprehension REF: p. 488

OBJ: Theory #3

TOP: Bulimia Nervosa

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

An obese clinic patient who is in the latter part of the first trimester of a pregnancy asks how much weight she should gain. The nurse's best response is to say that the total weight gain should be no more than:

1. 35 pounds.

2. 30 pounds.

3. 20 pounds.

4. 10 pounds.

ANS: C

Total weight gain for an obese patient should be no more than 20 pounds.

DIF: Cognitive Level: Comprehension REF: p. 490 Table 27-1

OBJ: Theory #4

TOP: Pregnancy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

The nurse takes into consideration that a patient who uses alcohol is at risk for a vitamin deficiency in:

1. thiamine.

2. cyanocobalamin.

3. ascorbic acid.

4. iron.

ANS: A

Thiamine deficiency is often present in patients who use alcohol.

DIF: Cognitive Level: Knowledge

REF: p. 490

OBJ: Theory #4

TOP: Substance Related and Addictive Disorders

KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

A patient who is on a low cholesterol diet verbalizes that he enjoys eating meats and does not intend to stop. The nurse's most helpful response would be, "You can enjoy your meat if you will concentrate on such meats as:

1. broiled sirloin steak."

2. fried catfish."

3. baked turkey breast."

4. sausage patties."

ANS: C

Red meat, eggs, and high-fat dairy products contain large amounts of saturated fat; poultry (such as turkey breast) and fish are low-fat items and therefore are desirable when trying to reduce serum cholesterol. Fried foods also contain extra cholesterol.

DIF: Cognitive Level: Comprehension REF: p. 491

OBJ: Theory #4

TOP: Patient Education

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

An older male patient is concerned about his cholesterol laboratory report that shows an elevated high density lipoprotein (HDL) level. The nurse explains that such a report indicates that:

1. he should go on a strenuous low cholesterol diet.

2. he is at risk for hypertension.

3. is developing atherosclerosis.

4. his vessels are being cleansed of fatty deposits.

ANS: D

High density lipoprotein (HDL) is the "good" cholesterol that tends to cleanse the vessels of fatty deposits.

DIF: Cognitive Level: Comprehension

REF: p. 491

OBJ: Theory #4

TOP: HDL

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

An outpatient clinic nurse assesses a blood glucose level of 75 mg/dL in a patient who has been on a low carbohydrate diet for the last 10 days. The nurse should:

1. notify the physician about the ineffectiveness of the diet.

2. document the finding.

3. suggest a moderate increase carbohydrate intake.

4. arrange a dietician consultation to discuss a more effective diet.

ANS: B

Document the finding. Normal blood sugar is between 70 and 120 mg/dL.

DIF: Cognitive Level: Application

REF: p. 491

TOP: Disease Process Benefiting from Nutritional Therapy

OBJ: Theory #5

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Because of the patient's dysphagia, the nurse recommends to the physician that the patient be placed on a Level Il texture level diet, which means that the food is:

1. thickened to prevent aspiration.

2. pureed to a pudding consistency.

3. mechanically altered, moist, minced helpings.

4. minced into bite size pieces.

ANS: C

Level II texture is a diet in which the food has been mechanically altered to moist, 1/4 inch pieces.

DIF: Cognitive Level: Comprehension REF: p. 495

OBJ: Theory #3

TOP: Nutritional Modifications

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

A nurse positions a patient for the insertion of a nasogastric (NG) tube by:

1. turning the patient to a right side lying position.

2. sitting the patient upright and hyperextending the patient's head.

3. lowering the head of the bed to a flat position.

4. raising the head of the bed to 30 degrees.

ANS: B

The head of the bed should be raised and the patient asked to hyperextend his head to facilitate the passage of the NG tube.

DIF: Cognitive Level: Application

REF: p. 497|Skill 27-2

OBJ: Theory #6

TOP: NG Tube Insertion

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

The nurse who is preparing to give a feeding per a nasogastric (NG) tube tests the placement of the tube most safely by:

1. checking the lungs for rhonchi.

2. instilling 10 mL of sterile water and checking for cough.

3. aspirating stomach contents.

4. injecting 20 mL of air and listen at the tip of the xiphoid.

ANS: C

The safest and most assured method to test for NG tube placement is to aspirate stomach contents and check fluid for pH. Using the air method is not as accurate as the stomach aspiration.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #3

REF: p. 497|Skill 27-2

TOP: NG Tube Insertion

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

Stopping the infusion and checking for residual volume, the nurse aspirates 250 mL of gastric contents. The nurse should next:

1. replace the aspirate and continue with the feeding.

2. throw the aspirate away and flush the tubing.

3. replace the aspirate and delay feeding for 1 to 2 hours.

4. throw the aspirate away and delay feeding for 2 hours.

ANS: C

If the residual volume is greater than 250 mL (or per agency policy), replace the withdrawn fluids, document the residual, and notify the RN or primary care provider (promotility medications may be ordered), and delay further feeding for 1 to 2 hours if facility policy states to do so.

DIF: Cognitive Level: Application

REF: p. 500

OBJ: Clinical Practice #4

TOP: Residual Volume

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient is scheduled to receive an intermittent tube feeding. This feeding should be allowed to flow in over how many minutes?

1. 1 minute

2. 2 minutes

3. 5 minutes

4. 10 minutes

ANS: D

An intermittent feeding should take approximately 10 minutes to flow into the tube.

DIF: Cognitive Level: Comprehension

REF: p. 500

OBJ: Theory #7

TOP: Tube Feeding

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

When the patient has just finished receiving a tube feeding, the nurse leaves the head of the patient's bed elevated for 30 to 60 minutes after feeding in order to:

1. facilitate stomach emptying and prevent aspiration.

2. maintain skin integrity to the buttocks.

3. facilitate lung drainage and promote ventilation.

4. prevent feeding tube from clogging.

ANS: A

The head of the bed should be left elevated at a 30-to 90-degree angle for 30 to 60 minutes after the feeding to help reduce the risk of aspiration.

DIF: Cognitive Level: Comprehension

REF: p. 501

OBJ: Clinical Practice #4

TOP: Tube Feeding

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

The nurse caring for the patient receiving total parenteral nutrition (TPN) should monitor the flow rate every:

1. 2 hours.

2. 3 hours.

3. 4 hours.

4. 6 hours.

ANS: C

Both the IV site and the flow rate should be monitored every 4 hours and the site assessed for infection.

DIF: Cognitive Level: Knowledge

REF: p. 504|Table 27-4

OBJ: Theory #8

TOP: TPN

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse explains that adequate vitamin D can be acquired by:

1. eating 2 oranges a day every week.

2. eating fish 3 times a week.

3. having 10 to 15 minutes of sunshine exposure per day.

4. eating green leafy vegetables.

ANS: C

10 to 15 minutes of sunshine exposure is sufficient to produce sufficient vitamin D for people with lighter skin

DIF: Cognitive Level: Comprehension

REF: p. 491

TOP: VitaminD KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse is caring for a patient who has total parenteral nutrition (TPN) running finds that the infusion is behind by 200 mL. The nurse should:

1. increase the flow rate 5% until the infusion has caught up.

2. check the patient's stomach residual volume.

3. elevate the head of the bed 30 degrees.

4. document the discrepancy and report to the charge nurse.

ANS: D

The rate of a TPN is never increased because of the danger of causing hyperglycemia or circulatory overload. The discrepancy is to be documented and reported to the charge nurse or physician.

DIF: Cognitive Level: Application

REF: p. 504

OBJ: Theory #1

TOP: Monitoring TPN

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient recently started on enteral tube feedings starts complaining of nausea and having diarrhea. The best nursing action is to:

1. check the enteral tube for placement.

2. slow down the feedings and monitor.

3. perform a fingerstick blood glucose test.

4. stop the feedings and inform the physician.

ANS: D

Nausea, constipation, and diarrhea are concerns following institution of tube feedings.

DIF: Cognitive Level: Application

REF: p. 504|Box 27-3

OBJ: Clinical Practice #4

TOP: Enteral Nutrition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient has a new order to have an NG tube removed. The nurse should initially:

1. wash her hands and apply clean gloves.

2. encourage mouth care as needed.

3. explain the procedure to the patient.

4. pinch the tube while removing it.

ANS: C

Explaining the procedure to the patient before starting helps in gaining the patient's confidence.

DIF: Cognitive Level: Application

REF: p. 500|Step 27-2

OBJ: Clinical Practice #3

TOP: NG Tube Removal

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

A nurse is instructing a family member who will be caring for a patient receiving enteral feedings after discharge to home. The nurse would emphasize:

1. taping the gastrostomy tube so that it does not hang lower than the stomach.

2. discarding unused opened refrigerated formula after 3 to 4 days.

3. administering tube feedings while they are still cold from the refrigerator.

4. mixing all medications together for administration at the same time.

ANS: A

The tube should be taped so that it is higher than the entry point into the body.

DIF: Cognitive Level: Application

REF: p. 505

OBJ: Clinical Practice #2

TOP: Health Education

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse inserting an NG tube through the nostril into the back of the throat of a patient would instruct the patient to:

1. hyperextend the head.

2. cough forcefully.

3. drop head forward and begin to swallow.

4. open mouth and extend tongue.

ANS: C

The patient should be instructed to tip the head forward and begin to swallow to help advance the tube through the esophagus.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #3

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment

REF: p. 498|Skill 27-2

TOP: NG Tube Insertion

The nurse caring for a patient receiving enteral feedings would assess for tolerance of the feeding by monitoring:

1. for gastric tube patency.

2. for duodenal tube patency.

3. for abdominal distention.

4. the rate of the feeding.

ANS: C

feedings.

Assessing the abdomen for distention helps the nurse identify the intolerance of tube

DIF: Cognitive Level: Application

OBJ: Clinical Practice #4

REF: p. 502|Skill 27-3

TOP: Enteral Nutrition

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

While the nurse is explaining the procedure for inserting a tube for enteral feedings, the patient interrupts and asks why there is a need for this tube. The nurse's best response is:

1. "Your physician has ordered this to help your condition."

2. "Tell me what your primary care provider told you about this procedure."

3. "Are you telling me you don't want this tube inserted?"

4. "This tube placement will only be temporary."

ANS: B

In assessing the patient's understanding, the nurse should assess the level of the patient's understanding and knowledge about the procedure.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #3

REF: p. 497|Skill 27-2

TOP: NG Tube Insertion

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Basic Care and Comfort

When caring for a patient receiving total parenteral nutrition, the nurse knows that it is essential to:

1. check the flow rate every shift.

2. order electrolytes daily.

3. monitor IV site every shift.

4. monitor the blood glucose.

ANS: D

Total parenteral nutrition contains a high concentration of glucose, and monitoring blood glucose every 6 to 8 hours will determine patient tolerance.

DIF: Cognitive Level: Comprehension

REF: p. 504

TOP: TPN

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

OBJ: Theory #10

A nurse instructs a patient who is to receive a soft diet that the diet will include: (Select all that apply.)

1. eggs.

2. multigrain bread.

3. baked potato.

4. soups.

5. fruit juices.

6. milk products.

ANS: A, D, E, F

Soft diets are low in fiber, and foods are softened by cooking, mashing, or chopping. Foods allowed on a soft diet include eggs, breads without seeds, boiled or mashed potatoes, soups, fruit juices, tender cooked vegetables, meat that is stewed, boiled or ground, cooked cereals, mashed bananas, applesauce, and milk products.

DIF: Cognitive Level: Comprehension

REF: p. 487

TOP: Nutrition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #1

When the patient complains about the insertion of the total parenteral nutrition (TPN) tube interfering with his movement, the nurse explains that the insertion in the subclavian vein allows: (Select all that apply.)

1. adequate dilution of TPN solution.

2. closer proximity to the heart.

3. more effective monitoring from the I pump.

4. for adequate blood flow.

5. for more ease in dressing insertion site.

ANS: A, D

The placement in the subclavian provides a large vein with large blood flow, which dilutes the TPN to keep venous irritation at a minimum and ensures better distribution.

DIF: Cognitive Level: Application

REF: p. 504

OBJ: Theory #10

TOP: Insertion Site

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse giving a bolus feeding through a nasogastric tube with a syringe would: (Select all that apply.)

1. pull up 50 mL of formula in the syringe.

2. lower the head of the bed to flat position.

3. allow feeding to flow in by gravity.

4. flush the tube with 50 mL of water.

5. check the position of the tube.

ANS: C, E

The nurse should roll up the head of the bed, check the placement of the tube, allow 30 mL of formula to flow in by gravity, and flush the tube with 30 mL of sterile water.

DIF: Cognitive Level: Application

REF: p. 497

TOP: Nutrition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

nurse caring for a patient diagnosed with AIDS would include in the nutritional plan of care: (Select all that apply.)

1. asking the patient about sexual history.

2. encouraging the patient to eat solid foods that are high in protein.

3. offering the patient supplements such as Ensure.

4. obtaining an order for a dietitian consult.

5. urging the patient to eat three well-balanced meals per day.

6. offering pureed foods when the patient's mouth is painful.

ANS: C, D, F

Solid food may be difficult to eat, so consulting with a dietitian and having the patient eat foods that are high in protein and that are bland or pureed are very appropriate. AIDS patients should eat small meals several times a day.

DIF: Cognitive Level: Application

REF: p. 493

OBJ: Theory #3

TOP: HIV/AIDS and Nutrition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse counsels the bulimic patient that her eating disorder can lead to serious conditions such as: (Select all that apply.)

1. esophageal ulcers.

2. diverticulitis.

3. ulcerative colitis.

4. peptic ulcers.

5. heart failure.

ANS: A, D

Long-term bulimic patients may acquire serious conditions such as esophageal and peptic ulcers.

DIF: Cognitive Level: Comprehension

REF: p. 488

OBJ: Theory #4

TOP: Feeding and Eating Disorders

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease