High Acuity Nursing 6th Edition by Kathleen Dorman Wagner – Test Bank

 

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Wagner, High Acuity Nursing, 6e
Chapter 5

Question 1

Type: MCSA

An older adult patient was hospitalized for 2 weeks before having abdominal surgery 3 days ago. The nurse notes the patient’s hair is broken and dull. Which intervention is indicated?

1. Increase vigilance for dehiscence.
2. Talk to the family about trimming the patient’s hair.
3. Use a protein-based shampoo.
4. Increase the patient’s oral fluid intake.

Correct Answer: 1

Rationale 1: Broken and dull hair may indicate protein-calorie malnutrition. If this condition exists it increases risk for dehiscence of the patient’s abdominal incision.

Rationale 2: Trimming the hair will not reverse the process that is likely occurring.

Rationale 3: External application of protein will not correct the probable source of this change in the patient’s hair.

Rationale 4: Increasing fluid will not change this situation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-1

 

Question 2

Type: MCSA

A patient with a BMI of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse’s focus regarding this patient’s nutritional needs?

1. Support elevated nutrient needs.
2. Maintain on intravenous fluids and clear liquids.
3. Limit food and fluid intake to three mealtimes daily.
4. Begin a weight-reduction program immediately.

Correct Answer: 1

Rationale 1: During acute illness it is crucial to meet the elevated nutrient needs of obese patients to optimize outcomes.

Rationale 2: Weight loss is not the focus of the patient’s current needs.

Rationale 3: There is no reason to limit food to three daily meals. Fluids should not be restricted unless there is a comorbid condition that requires decrease in fluid intake.

Rationale 4: Weight loss is not the focus of the postoperative period.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-1

 

Question 3

Type: MCSA

A patient admitted for a gunshot wound to the leg and multiple abdominal stab wounds is transferred to the intensive care unit after surgery. The nurse would evaluate which finding as expected but as requiring monitoring?

1. Blood pressure 170/104 mm Hg
2. Elevated blood glucose level
3. Serum potassium of 5.4 mEq/L
4. Increase in body temperature

Correct Answer: 2

Rationale 1: This blood pressure reading would not be expected with this patient’s mechanism of injury.

Rationale 2: The first 24 hours after a body injury, the body responds with an increase in mobilization of carbohydrates and lipids. Glucose production increases in efforts to support wound healing. The body also responds by decreasing the amount of insulin produced. Because of these bodily responses, the nurse will most likely observe an elevated blood glucose level that will impact the patient’s nutritional needs at this time. This finding is physiologically normal but will require monitoring as the patient heals.

Rationale 3: This potassium level is elevated and is not an expected finding.

Rationale 4: The first 24 hours after a body injury, the body responds with a drop in body temperature. Increased temperature is not an expected finding.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-1

 

Question 4

Type: MCSA

The nurse is planning a refeeding program for a patient diagnosed with cachexia from AIDS. Which nursing interventions are indicated?

1. Encourage the patient to eat as much as possible during each meal.
2. Plan to increase the patient’s calorie intake to goal in 2 or 3 days.
3. Limit the patient’s intake of fluids so to encourage a normal appetite.
4. Each day offer foods that provide 20kcal/kg of the patient’s actual body weight.

Correct Answer: 4

Rationale 1: If the patient ingests as much food as possible during each meal, the risk of refeeding syndrome will increase.

Rationale 2: The increase in calories to the established goal should be done slowly and may take as long as a week.

Rationale 3: Restriction of fluids is not indicated, will not necessarily stimulate a normal appetite, and may place the patient at risk for fluid volume deficit.

Rationale 4: The patient with cachexia from AIDS is at risk for developing refeeding syndrome. In efforts to reduce this risk, the patient’s daily calorie intake should equal 20 kcal/kg of body weight.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-5

 

Question 5

Type: MCSA

The nurse is caring for a patient with a history of hypercapnea. What should the nurse include when planning for this patient’s nutritional needs?

1. Monitor carbohydrate intake to reduce body carbon dioxide levels.
2. Encourage fat intake.
3. Minimize vitamin supplements.
4. Limit protein.

Correct Answer: 1

Rationale 1: Limiting the carbohydrate intake in a patient with a history of hypercapnea would be beneficial in efforts to reduce the body’s carbon dioxide load.

Rationale 2: Fat is calorie intense and patients with excessive overall calorie intake may have increased carbon dioxide levels.

Rationale 3: Vitamin supplements should be provided according to the patient’s needs and not minimized unless necessary.

Rationale 4: The patient’s protein should not be limited but rather calculated to meet the patient’s needs.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-1

 

Question 6

Type: MCSA

The nurse is caring for a patient diagnosed with chronic renal failure and being treated with hemodialysis who weighs 100 kg. What would be an appropriate intake of protein for this patient?

1. 120 g per day
2. 75 g per day
3. 240 g per day
4. 60 g per day

Correct Answer: 1

Rationale 1: The patient with renal failure receiving maintenance hemodialysis would benefit from receiving a protein intake of 0.8 to 2.0 g/kg per day. The patient weighs 100 kg and therefore a daily intake of 120 g of protein per day would be appropriate.

Rationale 2: 75 g of protein is equal to 0.75 g/kg, which is too low for this patient.

Rationale 3: 240 g of protein is equal to 2.4 g/kg, which is too high for this patient.

Rationale 4: 60 g of protein is 0.6 g/kg and is too low for this patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-2

 

Question 7

Type: MCSA

A patient, being treated for multiple injuries in the intensive care unit, had been NPO for several days. Clear liquids are started today, but the patient only takes a few sips before refusing additional fluids and then vomiting. The patient’s temperature is also elevated. The nurse would assess for findings associated with which disorder?

1. Gastric ulcer
2. Gut failure
3. Electrolyte imbalance
4. Diabetes insipidus

Correct Answer: 2

Rationale 1: Inability to tolerate fluids after being NPO would not be a primary indicator of gastric ulcer.

Rationale 2: During periods of high stress, the body will shunt blood to the organs to maintain maximum functioning. When this occurs, the gastrointestinal tract could develop ischemia and atrophy. The introduction of food or fluids at this time could cause the patient to vomit and have complaints of early satiety. With an ischemic gut, the patient is prone to developing bacterial translocation, which means bacteria enter the general circulation from the gastrointestinal tract. This is a major cause of sepsis with the body response as an increase in temperature.

Rationale 3: Inability to tolerate fluids after being NPO would not indicate an electrolyte imbalance.

Rationale 4: Inability to tolerate fluids after being NPO would not indicate diabetes insipidus.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-2

 

Question 8

Type: MCSA

The nurse is caring for a patient who sustained burns of 40% of the total body surface area. What would the nurse plan to meet this patient’s nutritional needs?

1. Supply with balanced nutrients to meet current body weight needs.
2. Complete a nutritional assessment and supply with high-calorie, high-protein supplements.
3. Provide high dose therapy of vitamins C and B.
4. Supply with high-fat and high-carbohydrate supplements.

Correct Answer: 2

Rationale 1: Because of the hypermetabolic status of the patient, the patient needs more calories than those needed to meet current body weight needs.

Rationale 2: The patient recovering from a burn injury of 40% of the total body surface should have a complete nutritional assessment and then be supplied with high calorie, high protein supplements to meet the body’s hypermetabolic and healing needs.

Rationale 3: Standardized protocols for vitamin supplementation should be followed.

Rationale 4: High fat and high carbohydrate are not the primary needs for this patient.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-2

 

Question 9

Type: MCSA

The nurse is caring for a patient who is comatose after a traumatic brain injury. What is important for the nurse to include when planning for this patient’s nutritional needs?

1. Provide adequate calories in the form of carbohydrates and fats.
2. Ensure adequate protein intake to maintain a positive nitrogen balance.
3. Plan to implement parenteral nutrition as soon as possible.
4. Increase dietary supply of cortisol.

Correct Answer: 2

Rationale 1: Calories should be provided to support all nutritional needs and not focus on carbohydrates and fats.

Rationale 2: In the patient with a traumatic brain injury, providing adequate energy and protein for a positive nitrogen balance is paramount to successful treatment, and aggressive nutrition support is recommended.

Rationale 3: Because patients with traumatic brain injury often have poor cough or gag reflex they are at risk of pulmonary aspiration. Enteral nutrition is the preferred alternative to oral nutrition.

Rationale 4: Patients with traumatic brain injury have massive release of catecholamines and cortisol. Cortisol in not added by nutritional means.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-2

 

Question 10

Type: MCSA

A patient, in the intensive care unit, has been NPO for several days. The nurse is unable to assess bowel sounds. What should be included in to the plan to support this patient’s nutritional needs?

1. Maintain NPO status.
2. Prepare to assist with implementation of a large bore venous access device to support total parenteral nutrition.
3. Determine best enteral feeding approach and plan implementation.
4. Begin oral feeding with a diet as tolerated as soon as bowel sounds return.

Correct Answer: 3

Rationale 1: The patient should not be maintained on NPO status only because of the absence of bowel sounds.

Rationale 2: Total parenteral nutrition might expose the patient to unnecessary pathogens which could compromise the healing process.

Rationale 3: Readiness for enteral feeding should not be determined by the presence of bowel sounds. Active bowel sounds have been used as criteria to initiate feeding, but there is no scientific evidence to support this practice. Bowel sounds are a poor indicator of small bowel motility and nutrient absorption, as they are the result of air passing through the intestinal tract.

Rationale 4: The patient may or may not be able to tolerate oral feedings with a diet as tolerated. Nutritional support should not wait until the presence of bowel sounds.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-3

 

Question 11

Type: MCMA

The nurse is assessing a patient’s ability to receive enteral feedings. Which findings would the nurse evaluate as potential contraindications to this intervention?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient has a history of Crohn’s disease.
2. The patient has a gastric ulcer.
3. There is a mechanical obstruction.
4. The patient has developed hemorrhagic pancreatitis.
5. The patient has had severe intractable diarrhea for 3 days.

Correct Answer: 3,4,5

Rationale 1: History of Crohn’s disease is not a contraindication for enteral therapy.

Rationale 2: Presence of gastric ulcer is not a contraindication to enteral feeding but may be a determinant of type of feeding tube chosen.

Rationale 3: Contraindications to enteral nutrition have diminished as its safety and efficacy has been demonstrated in many types of high-acuity patients. Mechanical obstruction is the only absolute contraindication to enteral feedings.

Rationale 4: Severe hemorrhagic pancreatitis is a relative contraindication to enteral feeding.

Rationale 5: Severe intractable diarrhea is a relative contraindication to enteral feeding.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-3

 

Question 12

Type: MCSA

A patient, with a history of aspiration pneumonia, is going to receive enteral feedings. What should be considered regarding the tube and placement for this patient?

1. Postpyloric feedings need to be interrupted and would not support the patient’s nutritional needs.
2. Postpyloric feedings have less incidence of pneumonia in some groups and would be preferred for this patient.
3. Gastric feedings provide more calories and better tolerance.
4. Gastric feedings are ideal as long as the patient is receiving a proton pump inhibitor.

Correct Answer: 2

Rationale 1: Postpyloric feedings do not need to be interrupted as much as gastric feedings.

Rationale 2: Because it is documented that postpyloric feedings can be provided with less interruption and a higher nutritional intake and there is a lower incidence of pneumonia in some patients this technique should be considered for the patient.

Rationale 3: Gastric feedings are usually interrupted and would not necessarily provide more calories for the patient.

Rationale 4: The use of a proton pump inhibitor does not decrease the risk of gastric feeding related pneumonia.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5-3

 

Question 13

Type: MCSA

A patient receiving nasogastric tube feedings has a gastric residual volume of 450 mL. Which nursing intervention is indicated?

1. Hold the tube feeding until the gastric aspirate is less than 100 mL.
2. Provide the tube feeding as a bolus.
3. Hold the tube feeding until the gastric aspirate is less than 250 mL.
4. Provide the tube feeding as a continuous infusion.

Correct Answer: 3

Rationale 1: It is not necessary to wait until the gastric residual volume is less than 100 mL since this is a nasogastric tube and not a gastrostomy tube.

Rationale 2: Introducing a bolus feeding would quickly increase the amount of feeding in the stomach and is not indicated.

Rationale 3: A common intervention for high gastric residual volume is to hold the enteral feeding for 1 to 2 hours until the residual volume is less than 200 to 250 mL from a nasogastric tube.

Rationale 4: Additional tube feeding should not be introduced at this time.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-3

 

Question 14

Type: MCSA

A patient has a clogged postpyloric feeding tube. Which nursing intervention is indicated?

1. Irrigate the tube with a large amount of pressure to break the clog.
2. Pull the tube and insert another.
3. Slowly attempt to irrigate the tube with warm water.
4. Use a stylet to break through the clog.

Correct Answer: 3

Rationale 1: The nurse should not irrigate the tube with large amounts of pressure.

Rationale 2: Efforts should be undertaken to dislodge the clog before pulling the tube and inserting another.

Rationale 3: To dislodge a clogged tube, irrigate the tube with warm water, cola, or juice. Also, using a syringe with alternating positive and negative pressure can dislodge a clog.

Rationale 4: Using a stylet to break up a clog can cause an esophageal or gastric mucosa tear.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-3

 

Question 15

Type: MCMA

The nurse is caring for a patient with a large bore catheter for total parenteral nutrition. Which findings would indicate to the nurse that the patient might be experiencing catheter related sepsis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sudden glucose intolerance
2. Leukocytosis
3. Sudden onset of chills
4. Sudden onset chest pain
5. Tenderness at the insertion site

Correct Answer: 1,2,3,5

Rationale 1: Sudden glucose intolerance may occur up to 12 hours before a temperature elevation occurs and is an indicator of catheter-related sepsis.

Rationale 2: Leukocytosis will occur as the patient’s immune system begins to fight the infection.

Rationale 3: The patient may be experiencing chills for a number of reasons, but the nurse should consider the possibility of catheter-related sepsis.

Rationale 4: Sudden onset chest pain may occur if a pneumothorax develops but is not associated with catheter related sepsis.

Rationale 5: Infection at the site of insertion can be manifested by tenderness or erythema. Infection at this site is considered a catheter-related infection and can lead to sepsis.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4

 

Question 16

Type: MCSA

A patient receiving total parenteral nutrition has elevated serum blood urea nitrogen and serum sodium levels. The nurse would conduct additional assessment for which complication?

1. Prerenal azotemia
2. Hyperglycemia
3. Catheter related sepsis
4. Hepatic dysfunction

Correct Answer: 1

Rationale 1: Prerenal azotemia is caused by overaggressive protein administration and is aggravated by underlying dehydration. Presenting signs and symptoms include an elevated serum BUN, serum sodium, and clinical signs of dehydration.

Rationale 2: Hyperglycemia is indicated by blood glucose level of greater than 220 mg/dL while receiving total parenteral nutrition.

Rationale 3: Signs and symptoms of catheter related sepsis include sudden onset of fever, rigors, or chills that coincide with parenteral infusion; erythema, swelling, tenderness, or purulent drainage from the catheter site; sudden temperature elevation that resolves on catheter removal; leukocytosis; sudden glucose intolerance that may occur up to 12 hours before temperature elevation; and bacteremia/septicemia/septic shock.

Rationale 4: Hepatic dysfunction would be assessed with serum liver function tests and bilirubin levels.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4

 

Question 17

Type: MCSA

After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea. The nurse is concerned that pneumothorax may be occurring. Which assessment findings would support this concern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

1. Restlessness
2. Chest pain
3. Decrease in pulse oximetry reading
4. Severe headache
5. Combativeness

Correct Answer: 2

Rationale 1: Restlessness may occur as pneumothorax increases in size.

Rationale 2: Chest pain is a common finding during pneumothorax.

Rationale 3: Hypoxia will occur as pneumothorax size increases.

Rationale 4: Headache is not associated with development of pneumothorax.

Rationale 5: Combativeness is not a common result of pneumothorax.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-4

 

Question 18

Type: MCMA

A patient is suspected of having an air emboli from a central venous line inserted for total parenteral nutrition. What nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Place the patient on the left side.
2. Place the patient in Trendelenburg position.
3. Occlude the catheter nearest to the entry site of the skin.
4. Notify the physician and prepare to take the patient to surgery.
5. Prepare to assist with chest tube insertion.

Correct Answer: 1,2,3

Rationale 1: When air embolus is suspected, immediate action is required. The patient should be placed on the left side. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.

Rationale 2: When air embolus is suspected, immediate action is required. The patient should be placed in the Trendelenburg position. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.

Rationale 3: The nurse should prevent additional air from entering the circulatory system by occluding the catheter as close as possible to where it enters the skin.

Rationale 4: Surgical intervention is not necessary.

Rationale 5: Chest tubes are not used in the treatment of air embolism.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-4

 

Question 19

Type: MCMA

The nurse is concerned that refeeding syndrome may be occurring in a patient receiving enteral nutrition. Which laboratory values would support this concern?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Serum potassium is 3.4 mEq/L
2. Fasting blood glucose is 98mg/dL
3. Hemoglobin is 10.8 g/100mL
4. Serum sodium of 138 mEq/L
5. Chloride of 98 mmol/L

Correct Answer: 1,3

Rationale 1: Hypokalemia is one of the electrolyte imbalances associated with refeeding syndrome.

Rationale 2: Hyperglycemia is more likely to occur with refeeding syndrome.

Rationale 3: Anemia can occur as a result of refeeding syndrome.

Rationale 4: This is a normal serum sodium level.

Rationale 5: This is a normal chloride level.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5-5

 

Question 20

Type: MCSA

A patient has been started on tube feeding by nasogastric tube. When his wife visits she says, “I need to tell you that my husband is lactose intolerant so that feeding will make him sick.” What nursing response is indicated?

1. “Even though the tube feeding fluid looks like milk it is lactose-free.”
2. “We did not know that. I will contact his physician immediately.”
3. “Since he is being fed by tube, the fact that he is lactose intolerant is not an issue.”
4. “We will watch to see if he has any symptoms of lactose intolerance.”

Correct Answer: 1

Rationale 1: Commonly used tube feedings are lactose-free.

Rationale 2: There is no need to contact the physician.

Rationale 3: The process of tube feeding does not change the concern over the patient being lactose intolerant.

Rationale 4: The nurse should educate the wife about tube feeding.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5-3