Deck 12: Promoting Nutrition

Question 1

The patient with impaired swallowing begins to choke while eating.Which action should 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.

Answer 1

Suction the airway until clear.

Question 2

A patient with a neurological disease has difficulty swallowing.Which should 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.

Answer 2

Allow adequate time for the feeding.

Question 3

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

Answer 3

Lobster chowder

Question 4

The nurse assists the patient who had a recent cerebral vascular accident (CVA or stroke)with 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.

Question 5

The nurse wants to know if the nursing plan of care is effective for a male patient with malnutrition.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 his last meal.
C) He weighs 185 pounds at 5 feet 6 inches tall.
D) He has reddish-pink mucous membranes.

Question 6

The nurse plans care for a patient with impaired swallowing.Which outcome would be appropriate for the nurse to include in the patient's plan of care?

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 swallows four times after each mouthful.

Question 7

The healthcare provider has started the patient on a clear liquid diet.Which item should the nurse provide for the patient?

A) Orange juice
B) Ice cream
C) Cranberry juice
D) Vegetable juice

Question 8

The nurse receives a report stating that the patient,who is 5 feet tall,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) Weight of 104 pounds

Question 9

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.

Question 10

A male patient with a neurological injury is learning how to feed himself.Which method should the nurse implement to best facilitate learning?

A) Delay self-feeding until the hand tremors subside.
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.

Question 11

The nurse admits a patient who follows the Hindu faith.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

Question 12

The nurse at a community center is preparing a program for elderly 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.

Question 13

The healthcare provider prescribes a dental-soft diet for the patient.Which food selection should the nurse provide for the patient?

A) White toast with peanut butter
B) Pancakes with sliced bananas
C) Scrambled eggs with bacon
D) Baked lasagna with meat sauce

Question 14

The nurse teaches the patient about eating a soft diet at home.After teaching,the nurse asks the patient for an example of a suitable food on a soft diet.Which patient choice does the nurse accept as suitable for a 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

Question 15

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 the amount of food spilled.
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 communication.

Question 16

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.

Question 17

An older patient has been eating approximately 50% of each meal for several days.Which action should 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.

Question 18

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 healthcare provider for full liquids.
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.

Question 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 20 to 25 cm (7.9 to 9.8 inches).
B) The tube coils in the oropharynx.
C) The patient has trouble swallowing.
D) The patient looks slightly cyanotic.

Question 20

The nurse plans care for four patients and assigns patient feeding to nursing assistive personnel (NAP).Which patient should the nurse watch during mealtime?

A) The patient who refuses most of the meals served
B) The patient who is learning to use adaptive utensils
C) The patient who swallows four times for each piece of food
D) The patient who is taking ice chips on the first postoperative day

Question 21

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 should the nurse implement?

A) Insert a nasogastric tube.
B) Withhold the next feeding.
C) Notify the patient's healthcare provider.
D) Administer the next feeding.

Question 22

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.

Question 23

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 to 15 minutes
D) 30 to 45 minutes

Question 24

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.

Question 25

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 until the bag empties completely.

Question 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.

Question 27

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 to 32 breaths/min.
B) The residual volume is less than 100 mL.
C) A 4-pound weight loss has occurred over 1 month.
D) Urine output has increased from 10 to 15 mL/hr.

Question 28

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 healthcare provider.

Question 29

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 healthcare provider before initiating the feeding?

A) An intact gag reflex
B) An occluded right naris
C) Impaired swallowing
D) Absent bowel sounds

Question 30

The nurse instructs the new orientee to care for the gastrostomy site.Which items should 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.

Question 31

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

Question 32

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

Question 33

Before administering a continuous nasointestinal tube (NIT)feeding,the nurse verifies placement of the patient's NIT and flushes it with water.Which step should the nurse perform next?

A) Instill the formula immediately after removing it from refrigeration.
B) Infuse the formula over 10 to 15 minutes.
C) Raise the syringe 18 inches above the insertion site.
D) Attach the feeding bag to the proximal end of the NIT.

Question 34

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.

Question 35

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

Question 36

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

Question 37

The patient receives three different medications through a nasogastric tube (NGT).Which fluid volume does the nurse anticipate instilling to administer medications by NGT properly?

A) 30 mL
B) 60 mL
C) 120 mL
D) 150 mL

Question 38

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) Store opened cans of formula in the refrigerator.