Assess area of skin to be used as puncture site
Explain procedure and purpose to patient and/or family
Check code on test strip vial
Clean puncture site with antiseptic solution
Gently squeeze fingertip until a drop of blood appears
Wick blood drop into test strip
Read results and document in medical record
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Terms in this set (42)
The nurse is learning about the Mini Nutritional Assessment (MNA). What is the highest score on the test?
14
Which test should be performed to confirm the correct placement of a nasogastric (NG) tube?
An x-ray study
Auscultation of the
abdomen
Assessment of stomach content pH
Assessment of residual stomach contents
An x-ray study
After cardiac surgery, a patient is prescribed a diet to reduce cholesterol. Which amount would be the recommended cholesterol intake in this diet?
100 mg/day
Which hang time would be the maximum allowed for enteral feedings in an open system?
8 hours
The nurse is caring for a patient diagnosed with hemorrhoids and chronic constipation. Which information would the nurse share with the patient about diet? Select all that apply.
Food rich in fiber relieves constipation.
Fiber contributes calories to the body.
Fluid and fiber intake should be decreased.
Fiber is well digested by humans.
Fruits and vegetables relieve
constipation.
Food rich in fiber relieves constipation.
Fluid and fiber intake should be increased.
Fruits and vegetables relieve constipation.
The nurse has a new prescription to monitor blood glucose on a patient, so the nurse provides information about the procedure and its purpose to the patient before taking the first measurement. Which phase of the nursing process is represented?
Planning
Evaluation
Assessment
Implementation
Planning
A patient is 5 feet 10 inches tall and weighs 70 kg. Which result would be the body mass index (BMI) of the patient?
22.09
Which food item contains gluten and should be avoided in patients with celiac disease? Select all that apply.
Wheat
Rye
Barley
Oats
Rice
Wheat
Rye
Barley
Oats
A patient needs enteral feedings via a nasoenteric tube. Which action would not occur during the assessment phase for this patient?
Explaining the procedure to the patient
Examining the abdomen of the patient
Asking the patient about food allergies
Evaluating the patient's nutritional status
Explaining the procedure to the patient
For which complication would the nurse be on alert in a patient who is on parenteral nutrition? Select all that apply.
Pulmonary aspiration
Delayed gastric emptying
Hyperglycemia
Electrolyte imbalance
Hypercapnia
Hyperglycemia
Electrolyte imbalance
Hypercapnia
A patient who myasthenia gravis has difficulty swallowing. For which complication of dysphagia would the nurse be observant? Select all that apply.
Aspiration pnemonia
Dehydration
Weight loss
Dental caries
Gastric ulcers
Aspiration pnemonia
Dehydration
Weight loss
A postoperative patient is prescribed clear liquids. Which fluid would the nurse provide? Select all that apply.
Tea
Coffee
Carbonated beverages
Vegetable juices
Blended cream soups
Tea
Coffee
Carbonated beverages
A patient is admitted to the hospital poststroke with right-sided hemiplegia. The nurse suspects the patient has dysphagia. Which datum would confirm dysphagia in the patient? Select all that apply.
Coughing during eating
A change in voice tone after swallowing
Abnormal movements of the mouth, tongue, and lips
Slow, weak, imprecise, or uncoordinated speech
No pocketing of food in the oral cavity
Coughing during eating
A change in voice tone after swallowing
Abnormal movements of the mouth, tongue, and lips
Slow, weak, imprecise, or uncoordinated speech
Which clinical manifestation is an indication for enteral nutrition? Select all that apply.
Severe pancreatitis
Severe malabsorption
Difficulty chewing
Prolonged intubation
Anorexia nervosa
Difficulty
chewing
Prolonged intubation
Anorexia nervosa
A patient who lives alone comes to the clinic for a regular checkup. Upon assessment, the nurse finds that the patient has experienced a weight loss of 5 pounds and has a poor nutrition status. The nurse decides to assess the food preferences and dietary intake of this patient. Which question would the nurse ask? Select all that apply.
"How do you prepare your food?"
"How many meals do you
have in a day?"
"Do you buy food from the nearby store?"
"How many hours after eating do you go to bed?"
"Do you follow any special diet because of a medical condition?"
"How do you prepare your food?"
"How many meals do you have in a day?"
"Do you follow any special diet because of a medical condition?"
Which intervention would a nurse perform on a patient who is receiving total parenteral nutrition (TPN) and is displaying symptoms of hypoglycemia?
Maintain a constant infusion flow rate.
Discontinue the TPN immediately.
Check the TPN for supplemental electrolyte levels.
Administer an intravenous (IV) bolus of 50% dextrose.
Administer an intravenous (IV) bolus of 50% dextrose.
Which action is part of the assessment phase when caring for a patient diagnosed with malnutrition?
Determine
the patient's nutritional energy needs.
Involve the patient's family when designing interventions.
Select nursing interventions consistent with therapeutic diets.
Reassess signs and symptoms associated with altered nutrition.
Determine the patient's nutritional energy needs.
Which action would be the most important nursing intervention that the nurse would perform on a patient who is diagnosed with ineffective coping related to improper nutrition?
Teaching the patient about dietary guidelines
Encouraging the patient to take a short afternoon nap
Using an active listening approach when talking with the patient
Encouraging the patient to contact a friend and take a walk every day
Using an active listening approach when talking with the patient
The nurse is consulting with a patient about meal planning on an allocated budget. Which advice would the nurse provide to help ensure good nutrition on a budget? Select all that apply.
Plan menus a week in advance.
Avoid grocery shopping when hungry.
Replace cheese or bean dishes with meat.
Use evaporated milk for cooking.
Choose frying food over steaming.
Plan menus a week in advance.
Avoid grocery shopping when hungry.
Use evaporated milk for cooking.
Which factor contributes to peptic ulcer formation?
Spicy foods
Decreased gastrin production
Increased bicarbonate retention
Helicobacter pylori infection
Heliobacter pylori infection
The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment finding requires further intervention?
Gastric pH of 4.0 during placement
check
Weight gain of 1 pound over the course of a week
Active bowel sounds in the four abdominal quadrants
Gastric residual aspirate of 350 mL for the second consecutive time
Gastric residual aspirate of 350 mL for the second consecutive time
Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD?
Micrococcus
Staphylococcus
Corynebacterium
Helicobacter pylori
Helicobacter pylori
Which action taken by the nurse would be the most reliable confirmation of the correct position of a recently placed small-bore feeding tube?
Referring the health care provider to prescribe an x-ray film examination to check position
Confirming the distal mark on the feeding tube after
taping
Testing the pH of the gastric contents and observing the color
Auscultating over the gastric area as air is injected into the tube
Referring the health care provider to prescribe an x-ray film examination to check position
During which phase of the nursing process does the nurse consult other health care professionals to adopt the best nursing intervention for a patient diagnosed with nutritional disturbances?
Planning
Evaluation
Assessment
Implementation
Planning
Which result would be the body mass index (BMI) of a patient who is 90 kg in weight and 2.0 m tall?
22.5
Which enzyme do the chief cells of the stomach secrete?
Secretin
Pepsinogen
Cholecystokinin
Intrinsic factor
Pepsinogen
Which nutrient should be supplied to treat a patient who has the malnutrition effect of depressed T-cell distribution?
Biotin
Copper
Folic acid
Vitamin C
Folic acid
Which enteral formula type consists of milk-based, blended foods and can be prepared by hospital dietary staff or in a patient's home?
Polymeric
Modular
Elemental
Specialty
Polymeric
Which action would the nurse perform during the planning phase for a patient diagnosed with malnutrition?
Determine the patient's satisfaction with the nutritional therapy
Gather data from the patient regarding nutritional practices
Select nursing interventions consistent with the therapeutic diet
Reassess signs and symptoms associated with altered nutrition
Select nursing interventions consistent with the therapeutic diet
The nurse observes the assistive personnel (AP) performing the following action for a patient receiving continuous enteral feedings. Which intervention must the nurse address immediately?
Fastening the tube to the gown with tape
Placing the patient supine while giving a bath
Performing oral care for the patient
Elevating the head of the bed 45 degrees
Placing the patient in supine while giving a bath
An adult patient has a body mass index of 20 kg/m. Which conclusion regarding the patient's nutrition status would the nurse formulate?
Overweight
Imbalanced nutrition
Healthy weight
Morbidly obese
Healthy weight
Which patient is at high risk of dysphagia? Select all that apply.
A patient who coughs during eating
An individual who speaks consistently
A patient who has abnormal lip movements
One who has coordinated and precise speech
The patient with a change in voice tone after swallowing
A patient who coughs during eating
A patient who has abnormal lip movements
The patient with a change in voice tone after swallowing
A patient receiving total parenteral nutrition (TPN) asks the nurse why blood glucose is being checked because the patient does not have diabetes. Which response by the nurse is appropriate?
"TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range."
"The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely."
"Monitoring your blood glucose level helps determine the dose of insulin that you need to absorb the
TPN."
"Checking your blood glucose level regularly helps determine if the TPN is effective as a nutrition intervention."
"TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range."
A patient with hypertension comes to the clinic for a checkup. On assessment, the nurse finds that the patient has experienced a weight loss of 5 pounds and has a poor nutrition status. Which physical sign is indicative of poor nutrition status? Select all that apply.
Dry scaly lips
Pain in the chest region
Flaccid, wasted muscles
Tiredness after climbing stairs
Spoon-shaped and brittle nails
Dry scaly lips
Flaccid, wasted muscles
Spoon-shaped and brittle nails
The nurse is assisting a dysphagic patient with eating. Which action would the nurse avoid?
Providing
thick liquids
Sitting the patient upright during meal time
Giving large bites to stimulate the swallow reflex
Keeping the patient upright for 45-60 minutes after eating
Giving large bites to stimulate the swallow reflex
Which complication of dysphagia would the nurse be aware of? Select all that apply.
Aspiration pneumonia
Dehydration
Decreased nutrition status
Weight
loss
Gastrointestinal infection
Aspiration pneumonia
Dehydration
Decreased nutrition status
Weight loss
The nurse is caring for a patient who is on tube feedings. Which sign and/or symptom suggests intolerance to the feedings? Select all that apply.
High gastric residual
Nausea
Vomiting
Constipation
Cramping
High gastric
residual
Nausea
Vomiting
Cramping
Which assessment step is taken to prevent abnormal clotting mechanisms while monitoring blood glucose via skin puncture?
Determining if risks exist for performing a skin puncture
Avoiding areas of bruising and open lesions when performing the puncture
Assessing a patient's understanding of the purpose of glucose monitoring
Determining if specific conditions need to be met before sample
collection is done
Avoiding areas of bruising and open lesions when performing the puncture
Which intervention indicates a correct technique of nasogastric (NG) feedings?
Checking residual volume every 4 hours
Stimulating the gag reflex every 8 hours
Administering only small amounts of the feeding formula
Administering the feedings to the patient in a supine position
Checking residual volume every 4 hours
After an assessment of a patient, the nurse finds that the patient is malnourished. Which clinical manifestation would be observed during the patient's assessment? Select all that apply.
Body mass index (BMI) of 26
Poor muscle tone
Smooth, supple skin
Hair loss
Pale conjunctiva
Poor muscle tone
Hair loss
Pale conjunctiva
A postroke patient suffers from right-sided hemiplegia and dysphagia. Which complication of dysphagia might the nurse observe in the patient?
Aspiration pneumonia
Excess fluid intake
Improved nutrition status
Weight gain
Aspiration pneumonia
Which nursing student statement regarding the physiological components of the immune system indicates a need for further education?
"Malnourished skin results in slowed wound healing."
"Riboflavin is a vital nutrient for the respiratory system."
"Granulocytes and macrocytes require folic acid as a vital nutrient."
"Malnourished T-lymphocytes result in depressed T-cell distribution."
"Riboflavin is a vital nutrient for the respiratory system."
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