Chapter 06: Nutritional Support Sole: Introduction to Critical Care Nursing, 7th Edition

Multiple Choice

1. A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy?

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

Because of the high dextrose concentration, including the fluid and electrolyte content, the patient is placed at high risk for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a potential complication of enteral feedings; sepsis is a potential complication of parenteral nutrition. Fluid overload is possible but unlikely and is not a major complication of parenteral nutrition. Hyperglycemia is more of a concern than hypoglycemia with parenteral nutrition; however, renal insufficiency is not related to parenteral nutrition.

DIF: Cognitive Level: Remember/Knowledge REF: p. 85

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. To assess for paralytic ileus b. To maintain the patency of the feeding tube c. To monitor for skin breakdown on the nose d. To prevent aspiration of the feedings

2. A patient is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement?

ANS: D

Patients who are on a ventilator and who are receiving tube feedings are at a high risk for aspiration and ventilator-associated pneumonia. Assessment of tube placement will neither determine presence of paralytic ileus nor maintain patency. Assessment of tube placement is performed to minimize aspiration risk, not skin breakdown on the nose.

DIF: Cognitive Level: Remember/Knowledge REF: p. 85 | Table 6-4

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Basilic vein b. Femoral vein c. Radial artery d. Subclavian vein

3. The patient is to start parenteral nutrition. The nurse knows to prepare which site for catheter insertion?

ANS: D

Total parenteral nutrition is administered through a central intravenous line, such as the subclavian vein. Arteries are never used. The femoral site is avoided. The basilic vein is not a central site.

DIF: Cognitive Level: Remember/Knowledge REF: p. 80

OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer medications. b. Cap off and wait 24 hours before starting feedings. c. Obtain a chest radiograph. d. Start the tube feeding.

4. A patient has been admitted to the critical care unit after a stroke. After “failing” a swallow study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step?

ANS: C

Correct placement must be verified by radiograph before use of the tube for either feeding or administering medications. There is no reason to cap the tube and wait; once placement is verified, the tube can be used.

DIF: Cognitive Level: Apply/Application REF: p. 86 | Table 6-4

OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. Arginine b. Omega-3 fatty acids c. Branched-chain amino acids d. Vitamin A

5. A critically ill patient has a nonhealing wound and malnutrition. Which component of nutritional supplementation is most important for this patient to receive?

ANS: D

Vitamin A is vital for wound healing. Arginine is also important in wound healing but is more important for trauma and septic patients, as are omega-3 fatty acids. Branched-chain amino acids are very important for stressed patients who have liver dysfunction or ARDS.

DIF: Cognitive Level: Remember/Knowledge

OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 82 | Table 6-1 a. Add blue dye to the formula. b. Assess the residual every hour. c. Elevate the head of the bed 30 degrees. d. Provide feedings via continuous infusion.

6. A patient is being fed through a nasogastric tube placed in his stomach. The nurse would carry out which intervention to minimize aspiration risk?

ANS: C

The head of the bed should be kept elevated at least 30 degrees if possible during tube feedings to minimize reflux. Blue dye should not be used. Neither continuous feedings nor checking for residual will minimize aspiration.

DIF: Cognitive Level: Apply/Application

OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 86 | Table 6-4 a. Notify the provider. b. Assess the patient’s lungs and oxygen saturation. c. Stop the tube feeding. d. Slow the rate of the infusion.

7. A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. What action by the nurse takes priority?

ANS: C

Nausea and vomiting are signs of tube feeding intolerance. The nurse should first stop the feeding. Then the nurse can assess for other signs of intolerance and aspiration. After a complete assessment, the nurse would notify the provider.

DIF: Cognitive Level: Apply/Application

REF: p. 85

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Connect the feeding tube to suction. b. Continue the tube feeding. c. Decrease the tube feeding. d. Assess the patient’s gastric residual.

8. A patient is receiving enteral feedings and reports fullness and abdominal discomfort. What action by the nurse is best?

ANS: D

The patient may not be tolerating the tube feeding. The nurse should assess the gastric residual and hold the feeding if it is greater than 500 mL. The other actions are not warranted; the nurse needs further information before proceeding.

DIF: Cognitive Level: Apply/Application

REF: pp. 85-86 | Table 6-4

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Abdominal distension b. Absence of tympany on percussion c. Active bowel sounds d. Elevated blood glucose by fingerstick

9. In addition to residual stomach volume, what other evidence suggests feeding intolerance?

ANS: A

Abdominal distension is expected if the feedings are not being absorbed. Tympany occurs along with distension.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 85-86 | Table 6-4

OBJ: Discuss methods for evaluating nutritional status.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Clostridium difficile b. Escherichia coli c. Occult blood d. Ova and parasites

10. Approximately 5 days after starting tube feedings, a patient develops extreme diarrhea. A stool specimen is collected to check for which possible cause?

ANS: A

Patients receiving enteral nutrition who develop diarrhea are evaluated for antibioticassociated causes, including Clostridium difficile

DIF: Cognitive Level: Remember/Knowledge REF: p. 86 | Table 6-4

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

11. A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care?

NURSINGTB.COM a. Change the intravenous tubing every 24 hours. b. Infuse antibiotics through the intravenous line. c. Monitor the blood glucose every 6 hours. d. Monitor the fluid and electrolyte balance.

ANS: B

Medications should not be infused through the IV line infusing parenteral nutrition. The other actions are correct.

DIF: Cognitive Level: Apply/Application REF: p. 85

OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Albumin b. BUN c. Prealbumin d. Triglycerides

12. In evaluating a patient’s nutrition, the nurse would monitor which blood test as the most sensitive indicator of protein synthesis and catabolism?

ANS: C

Prealbumin is the most sensitive indicator of protein synthesis and catabolism.

DIF: Cognitive Level: Remember/Knowledge REF: p. 87 Laboratory Alert Box

OBJ: Discuss methods for evaluating nutritional status.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Aspirin b. Enoxaparin c. Ibuprofen d. Phenytoin

13. A patient is receiving enteral tube feedings and has developed drug-nutrient interactions. The nurse recognizes which drug as having the potential for causing drug-nutrient reactions?

ANS: D

Bioavailability of phenytoin is reduced when administered with enteral feedings. The other drugs do not have significant drug-nutrient interactions.

DIF: Cognitive Level: Remember/Knowledge REF: p. 85

OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Failure of the tight junctions allows bacteria to invade the GI tract. b. The gut lacks protective mechanisms; thus, infection is always a concern. c. Water is reabsorbed at the beginning of the colon. d. Without nutritional stimulation, mucosal villi atrophy.

14. Which statement is true about normal function of the gastrointestinal (GI) tract?

ANS: D

Mucosal villi replenish every 3 to 4 days; without nutritional stimulation, they atrophy. The other statements are false.

DIF: Cognitive Level: Remember/Knowledge REF: p. 77

OBJ: Review the anatomy and physiology related to utilization of nutrients.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

15. An important nutritional consideration in the elderly population is a. a decrease in protein requirements. b. an increase in caloric requirements with age. c. the potential for drug-nutrient interaction related to polypharmacy. d. the presence of other diseases that decrease caloric needs.

ANS: C

Patients taking multiple medications have a greater potential for drug-nutrient interactions; older adults may be taking multiple medications.

DIF: Cognitive Level: Remember/Knowledge REF: p. 79

OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

16. Objective data designating that the nutrition goals are not being met include a. hyperglycemia, normovolemia, and increased protein level. b. overhydration, hypoglycemia, and weight gain. c. weight gain, inconsistent glucose, and normovolemia. d. weight loss, elevated glucose, and dehydration.

ANS: D

When nutritional goals are not being met, the patient experiences weight loss, elevated glucose levels, and either overhydration or dehydration.

DIF: Cognitive Level: Remember/Knowledge REF: p. 87

OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Elemental protein formula b. Fiber-added formula c. High medium–chain triglyceride formula d. Lactose-free formula

17. A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate?

ANS: B

Added fiber helps to control blood glucose and reduce hyperlipidemia.

DIF: Cognitive Level: Analyze/Analysis REF: p. 83

OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

NURSINGTB.COM a. Gut overgrowth increases. b. Gastroparesis increases. c. Bacterial translocation is initiated. d. Gut mucosa is preserved.

18. Select the physiological reasoning behind enteral therapy as the preferred source of nutritional therapy.

ANS: D

Enteral feedings prevent bacterial overgrowth and potential bacterial translocation from the gastrointestinal tract and preserve the gut mucosa.

DIF: Cognitive Level: Remember/Knowledge REF: p. 81

OBJ: Review the anatomy and physiology related to utilization of nutrients.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. The patient with gallbladder obstruction b. The patient with ileitis c. The patient with distal colon resection d. The patient with jejunal tumor

19. The nurse identifies which patient at greatest risk for malabsorption of protein?

ANS: B

The ileum is where protein is broken down and absorbed; the patient with ileitis would be at greatest risk for protein malabsorption.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 78

OBJ: Review the anatomy and physiology related to utilization of nutrients.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

20. The best nursing approach to prevent feeding tube obstruction is to a. dilute the feeding to make it flow more easily. b. flush the tube every 4 hours with 20 to 30 mL of tap water. c. pass a stylet daily to keep the tubing clear. d. use a larger bore tube where possible.

ANS: B

Flushing the tubing every 4 hours helps prevent obstruction. Diluting tube feedings can cause water intoxication. Stylets are never used to clear a tube, and the smallest bore possible should be used for best tolerance.

DIF: Cognitive Level: Apply/Application

OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 84

21. Patients experiencing severe physiological stress increase their nutritional requirements to: a. 20 kcal/kg/day. b. 30 kcal/kg/day. c. 35 kcal/kg/day. d. 50 kcal/kg/day.

ANS: C

NURSINGTB.COM

Severely stressed individuals require 35 kcal/kg/day; 50 kcal/kg/day exceeds caloric needs. A total of 20 kcal/kg/day is less than normal caloric requirements. A total of 30 kcal/kg/day is the caloric requirement for a moderately stressed individual.

DIF: Cognitive Level: Remember/Knowledge

OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

22. Malnutrition contributes to infection risk by a. hampering normal gastrointestinal motility. b. impairing immune function. c. increasing blood glucose. d. increasing drug interactions.

ANS: B

Malnutrition impairs immune function.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 84 Evidence Based Practice

REF: Table 6-2

OBJ: Review the anatomy and physiology related to utilization of nutrients.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

23. A patient, who has a tube feeding, requires a chest x-ray study for evaluation of a cough. To reduce the risk of aspiration, the nurse: a. helps the radiology technician to position the patient to avoid dislodging the tube. b. slows the rate of the feedings until placement has been verified. c. cuts the infusion rate by half. d. stops feedings 10 to 15 minutes before placing flat to obtain the radiograph.

ANS: D

Temporarily stopping feedings when flat minimizes the risk of aspiration if the patient will be supine.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 86

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Multiple Response

1. Which statements about total parenteral nutrition are correct? (Select all that apply.)

a. assessing fluid volume status and preventing infection are important nursing considerations.

b. fingerstick glucose levels are assessed every 6 hours and prn.

c. total parenteral nutrition is administered through a feeding tube and pump.

NURSINGTB.COM d. total parenteral nutrition with added lipids provides adequate levels of protein, carbohydrates, and fats. e. soy-based lipids should not be given during the first week of a critical illness.

ANS: A, B, D, E

All are correct except administration via a feeding tube and pump. A tube and pump are used to deliver enteral nutrition.

DIF: Cognitive Level: Remember/Knowledge

REF: pp. 80-81

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Assess glucose levels every 6 hours. b. Change the tubing every 24 hours. c. Hold lipids when administering antibiotics through the same line. d. Monitor triglyceride levels periodically. e. Maintain elevation of the head of the bed.

2. Which interventions are critical during intravenous lipid administration? (Select all that apply.)

ANS: B, D

Lipids are very good media for bacterial growth; lipid tubing should be changed every 24 hours. Triglyceride levels must be monitored until stable when administering lipids. Glucose is monitored during treatment with parenteral nutrition, which contains a high level of glucose. Medications are not administered through the IV lines containing lipids or parenteral nutrition. Elevating the head of the bed is important for enteral (tube) feedings to prevent aspiration.

DIF: Cognitive Level: Apply/Application

REF: p. 85 |p. 87 Laboratory Alert Box

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. are most useful in heart failure and liver disease. b. are most useful in malabsorption syndromes. c. contain 2 kcal/mL and 70 g protein/L. d. include increased fiber. e. are especially good for patients with lung disease.

3. Calorie-dense feedings: (Select all that apply.)

ANS: A, C

Calorie-dense feedings are used when volume should be minimized and protein requirements are high, such as in heart failure or liver disease. They contain 2 kcal/mL and 70 g protein/L. Specific formulas, such as Oxepa, are available for lung disease.

DIF: Cognitive Level: Remember/Knowledge REF: p. 83 | Table 6-3

OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. diarrhea. b. elevated blood sugar. c. infection at the catheter site. d. volume overload. e. aspiration.

4. Risks of total parenteral nutrition include: (Select all that apply.)

ANS: B, C, D

Diarrhea and aspiration are more common with enteral tube feedings; the other risks are common with total parenteral nutrition.

DIF: Cognitive Level: Remember/Knowledge REF: p. 85

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. The amount of parenteral insulin is adjusted based on the previous 24-hour laboratory values. b. Insulin may be added to a parenteral nutrition solution. c. Subcutaneous insulin is used on a sliding scale during parenteral nutrition. d. Supplemental insulin is rarely required for patients receiving parenteral nutrition. e. Lingering hyperglycemia after parenteral nutrition has stopped requires continuing insulin.

5. Which of the following statements is true about insulin and parenteral nutrition? (Select all that apply.)

ANS: A, B, C

Hyperglycemia is common when receiving parenteral nutrition; insulin may be administered on a sliding scale for glucose control and/or added to the parenteral solution. The amount of insulin added to the parenteral solution is calculated based on the previous 24-hour laboratory values. Hypoglycemia can result from continuing the insulin after the parenteral nutrition is discontinued.

DIF: Cognitive Level: Remember/Knowledge

OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. At least 2307 kcal/day b. Juven formula c. 2 cal HN formula d. At least 1648 kcal/day e. Perative formula

6. A patient with severe burns had a dietitian consultation for nutritional support. The patient weighs 145 pounds. What recommendations by the dietitian does the nurse anticipate initiating? (Select all that apply.)

ANS: A, B

The severely stressed patient requires around 35 kcal/kg/day. This patient weighs 145 pounds, which is 65.9 kg. So this patient needs at least 2307 kcal/day. Juven is an appropriate formula; 2 cal HN is used for patients with heart and/or liver disease and Perative is used for patients with impaired GI function.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 83 | Table 6-2 | Table 6-3

OBJ: Discuss the recommended nutritional support for a burn patient.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

Ordering

1. The correct order of actions for a patient starting enteral nutrition with a feeding tube is: _______________, _______________, _______________, _______________, _______________.

a. initiate tube feeding b. insert feeding tube c. flush tube to verify patency d. obtain chest radiograph e. assess residuals

ANS: B, D, C, A, E

Initially the feeding tube will be inserted and final placement verified via chest radiograph. The next step is to flush the feeding tube and start the tube feedings. Residuals are checked every 4 hours.

DIF: Cognitive Level: Apply/Application

OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 80-82