NURS1410: Unit II Enteral and Parenteral Nutrition NCLEX style question

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1. A client who is receiving total enteral nutrition (TEN) exhibits acute con-
fusion and shallow breathing and says, "I feel weak." As the client begins to
have a generalized seizure, how does the nurse interpret this client's signs
and symptoms?

A. The enteral tube is misplaced or dislodged.

B. Abdominal distention is present.
C. A fluid and electrolyte imbalance is present.
D. This is refeeding syndrome.: Answer D.

Rationale:
Incorrect: If the enteral tube becomes misplaced or dislodged, the client may
develop aspiration pneumonia displayed by increased temperature, increased
pulse, dehydration, diminished breath sounds, and shortness of breath.
Incorrect: Abdominal distention is most frequently accompanied by nausea and
vomiting.
Incorrect: Signs and symptoms of fluid and electrolyte problems resulting in cir-
culatory overload can include peripheral edema, sudden weight gain, crackles,
dyspnea, increased blood pressure, and bounding pulse.
Correct: Symptoms of refeeding syndrome include shallow respirations, weakness,
acute confusion, seizures, and increased bleeding tendency.
2. A client receiving total parenteral nutrition (TPN) exhibits symptoms of
congestive heart failure (CHF) and pulmonary edema. Which complication
of TPN is the client most likely experiencing?

A. Calcium imbalance
B. Fluid volume deficit
C. Fluid volume overload
D. Potassium imbalance: Answer C.

Rationales:
Incorrect: This client's symptoms are not indicative of calcium imbalance.
Incorrect: This client's symptoms are not indicative of fluid deficit.
Correct: Congestive heart failure and pulmonary edema are symptoms of fluid
overload
Incorrect: This client's symptoms are not indicative of potassium imbalance.
3. A client is discharged home with an enteral feeding tube. What does the
home health nurse do to determine the patency of the client's enteral tube?
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A. Arranges for the client to have an x-ray performed periodically

B. Auscultates the client's abdomen for bowel sounds before each feeding
C. Instills air into the tube to check for placement and patency before each
feeding
D. Tests aspirated tube contents for pH level before each feeding Correct: -
Answer D.

Rationales:
Incorrect: The client should have an x-ray performed when the enteral tube is
initially inserted.
Incorrect: The presence of bowel sounds does not indicate that the enteral tube is
in place.
Incorrect: This traditional auscultatory method for checking enteral tube placement
is not reliable, especially for the client with a small-bore tube.
Correct: This is considered to be the most accurate method for confirming enteral
tube placement.
4. A nurse is monitoring a client who is receiving an intravenous fat emulsion
(IVFE) nutritional supplement. What action does the nurse take in the event
that the client develops fever, increased triglycerides, and clotting problems?

A. Discontinues the IVFE infusion

B. Documents the findings and continues to monitor
C. Slows the rate of flow of the IVFE infusion
D. Switches the infusion to total parenteral nutrition (TPN) infusion: Answer
A.

Rationales:
Correct: For clients receiving fat emulsions, monitor for manifestations of fat
overload syndrome, especially in those who are critically ill. These manifestations
include fever, increased triglycerides, clotting problems, and multi-system organ
failure. Discontinue the IVFE infusion, and report any of these changes to the
health care provider immediately if this complication is suspected.
Incorrect: Documenting the findings and continuing to monitor will have serious
repercussions for this client. The IV must be stopped.
Incorrect: Slowing the rate of flow of the IVFE infusion will present a serious safety
risk for the client. The IVFE needs to be stopped.
Incorrect: Nurses do not request IV parenteral therapies or change them unless
the health care provider makes the decision.
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5. A nurse is teaching a class of older adults in the community about engag-
ing in "regular" exercise. What does the nurse advise them?

A. "1 to 2 hours of cardiovascular exercise every day is a good idea."

B. "Joining a fitness program or gym will help greatly with your exercise."
C. "Walking 20 minutes provides the same benefit as long periods of exer-
cise."
D. "You will benefit most if you get into a group that shares your exercise
goals.": Answer C.

Rationales:
Incorrect: 1 to 2 hours of cardiovascular exercise every day is not required to
achieve benefits of exercise.
Incorrect: A fitness program or gym is not necessary to achieve a regular exercise
workout. It is expensive, and many older adults have a fixed income and cannot
afford memberships.
Correct: Although some people think that regular exercise has to include joining a
fitness program or exercising for long periods of time, simple forms of exercise like
walking 20 minutes provide the same type of benefit. Older adults can engage in
this type of exercise. It does not cost money (like joining a program) and provides
health benefits such as strengthening joints and improving cardiovascular health.
Incorrect: A 20-minute walk can be accomplished with a group (such as "mall
walking") or alone. Some people like and want to have this time to themselves.
6. An RN who usually works on the pediatric unit is floated to the GI med-
ical-surgical unit. Which client is appropriate for the charge nurse to assign
to the float nurse?

A. 20-year-old with anorexia nervosa receiving total parenteral nutrition

(TPN) through a central venous line
B. 35-year-old who had a laparoscopic gastroplasty yesterday and is now
taking sips of clear liquids
C. 60-year-old with gastric cancer receiving elemental feedings through a
jejunostomy tube
D. 65-year-old with morbid obesity who requires a preoperative bariatric
surgery assessment: Answer A.

Rationales:
Correct: A pediatric nurse would be familiar with the pathophysiology and collabo-
rative treatment of the client with anorexia nervosa.
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Incorrect: The client with a laparoscopic gastroplasty requires more familiarity with
adult nutritional disorders and bariatric surgery.
Incorrect: The client with gastric cancer receiving elemental feedings through a
jejunostomy tube requires more familiarity with adult nutritional disorders and
bariatric surgery.
Incorrect: The client with morbid obesity who requires a preoperative bariatric
surgery assessment requires more familiarity with adult nutritional disorders and
bariatric surgery.
7. A nurse manager in a long-term care facility plans nutritional assessments
of all residents. Which nutritional assessment activity does the nurse dele-
gate to unlicensed assistive personnel (UAP) at the facility?

A. Assessing residents' abilities to swallow

B. Determining residents' functional status
C. Measuring the daily food and fluid intake of residents
D. Screening a portion of the residents with the Mini Nutritional Assessme-
: Answer C.

Rationales:
Incorrect: Assessing residents' abilities to swallow requires broad knowledge of
normal physiology, nutrition, and factors that impact on nutrition and should be
done by licensed nursing staff.
Incorrect: Determining residents' functional status requires broad knowledge of
normal physiology, nutrition, and factors that impact on nutrition and should be
done by licensed nursing staff.
Correct: UAP education includes measurement of clients' oral intake; this skill does
not require clinical judgment to be completed accurately.
Incorrect: Screening with the Mini Nutritional Assessment requires broad knowl-
edge of normal physiology, nutrition, and factors that impact on nutrition and should
be done by licensed nursing staff.
8. A client has a primary problem of inadequate nutrition caused by the
effects of chemotherapy. The client is receiving continuous enteral feedings
through a nasogastric tube (NG) tube. What does the RN ask the LPN/LVN to
do for this client?

A. Assess nutritional parameters on the client every 3 days.

B. Check the residual volume of the NG tube every 4 hours.
C. Monitor the client for signs and symptoms of pneumonia.
D. Teach the client about the purpose of enteral feedings.: Answer B.
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Rationales:
Incorrect: Assessing nutritional parameters on the client is complex and requires
broad knowledge about the physiology associated with malnutrition and possible
complications of tube feedings. This activity should be performed by an RN.
Correct: Checking the residual volume of the client's NG tube every 4 hours is
within the scope of knowledge and practice for the LPN/LVN.
Incorrect: Monitoring the client for signs and symptoms of pneumonia is complex
and requires broad knowledge about the physiology associated with possible
complications of tube feedings. This activity should be performed by an RN.
Incorrect: Teaching the client about the purpose of enteral feedings is complex and
requires broad knowledge about the physiology associated with malnutrition and
possible complications of tube feedings. This activity should be performed by an
RN.
9. Which client on a medical-surgical unit does the charge nurse assign to
the LPN/LVN?

A. 28-year-old with morbid obesity who had bariatric surgery today

B. 30-year-old recently admitted with severe diarrhea and Clostridium diffi-
cile infection
C. 36-year-old whose family needs instruction about how to use a gastric
feeding tube
D. 39-year-old with a jejunal feeding tube who needs elemental feedings
administered: Answer D.

Rationales:
Incorrect: Initial assessment of a postoperative client requires RN education and
scope of practice.
Incorrect: Initial assessment of a new admission requires RN education and scope
of practice.
Incorrect: Client and family teaching requires RN education and scope of practice.
Correct: LPN/LVN education includes administration of tube feedings and associ-
ated client care and monitoring.
10. An RN receives the change-of-shift report about these clients. Which
client does the nurse assess first?

A. 30-year-old admitted 2 hours ago with malnutrition that is associated with

malabsorption syndrome
B. 45-year-old who had gastric bypass surgery and is reporting severe
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incisional pain
C. 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose
(BG) level of 300 mg/dL
D. 75-year-old with dementia who is receiving nasogastric feedings and has
a respiratory rate of 38 breaths/min: Answer D.

Rationales:
Incorrect: The client admitted 2 hours ago with malnutrition needs assessments
and/or interventions by the RN, but maintaining respiratory function in the client
with tachypnea is the highest priority.
Incorrect: The client who had gastric bypass surgery and is reporting severe
incisional pain needs assessments and/or interventions by the RN, but maintaining
respiratory function in the client with tachypnea is the highest priority.
Incorrect: The client receiving TPN with a BG level of 300 mg/dL needs assess-
ments and/or interventions by the RN, but maintaining respiratory function in the
client with tachypnea is the highest priority.
Correct: Aspiration is a major complication in clients receiving tube feedings,
especially in clients with an altered level of consciousness. This client needs
respiratory assessment and interventions immediately.
11. A nurse obtains assessment data on a client who had bariatric surgery
today. Which finding does the nurse report to the surgeon immediately?

A. Bowel sounds are not audible in all quadrants.

B. Client's skin under the panniculus is excoriated.
C. The client reports pain when being repositioned.
D. Urine output total is 15 mL for the past 2 hours.: Answer D.

Rationales:
Incorrect: Inaudible bowel sounds may require nursing interventions but do not
require immediate intervention by the surgeon. On the day of surgery, they will
probably be absent normally for some time.
Incorrect: Excoriated skin under the panniculus may require nursing interventions
but does not require immediate intervention by the surgeon.
Incorrect: Subjective reports of pain may require nursing interventions but do not
require immediate intervention by the surgeon, as does the scant urine output.
Correct: Oliguria may indicate severe postoperative complications such as anas-
tomotic leaks or acute kidney failure.
12. Which nursing care activity for a malnourished client does the nurse
safely delegate to unlicensed assistive personnel (UAP)?
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A. Completing the Mini Nutritional Assessment

B. Determining body mass index (BMI)
C. Estimating body fat using skin-fold measurements
D. Measuring current height and weight: Answer D.

Rationales:
Incorrect: The nurse is responsible for completing the Mini Nutritional Assessment.
Incorrect: The nurse is responsible for determining the client's BMI.
Incorrect: The nurse is responsible for estimating body fat using skin-fold measure-
ments.
Correct: Determining height and weight is the only activity that can be safely
delegated to UAP.
13. Situation: An 87-year-old woman resident from an extended-care facility
has not been eating for several days. She is admitted to the hospital with
a diagnosis of malnutrition. She has an enteral feeding tube placed in her
left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac),
and potassium chloride elixir (Kay Ciel). The nurse who is responsible for
checking the gastric pH of the feeding tube tests it and obtains a value of
6.0. This finding may indicate that the feeding tube is in the client's lungs. Is
there another possible explanation for the nurse to consider?

A. No. The feeding tube must be removed.

B. No. The potassium effect will prevent the pH from reaching 6.0.
C. Yes. The client is taking Zantac.
D. Yes. The pH paper has expired and is giving a false reading.: Answer C.

Rationales:
Incorrect: This finding-given the circumstances-does not mean that the tube is
displaced and in the client's lungs.
Incorrect: The potassium effect does not cause the pH to become more alkaline.
Correct: The pH may be as high as 6.0 if the client takes certain medications, such
as H2 blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]).
Incorrect: Expired pH paper will provide no data that are reliable, so it would be
impossible to have a reading of "6."
14. Situation: An 87-year-old woman resident from an extended-care facility
has not been eating for several days. She is admitted to the hospital with
a diagnosis of malnutrition. She has an enteral feeding tube placed in her
left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac),
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and potassium chloride elixir (Kay Ciel). She has developed a severe case of
diarrhea. What is a possible cause?

A. Digoxin (Lanoxin)
B. Gastritis
C. Potassium chloride (Kay Ciel)
D. Ranitidine (Zantac): Answer C.

Rationales:
Incorrect: Diarrhea is not a frequent side effect of digoxin.
Incorrect: Gastritis does not cause diarrhea. The other signs and symptoms of
gastritis are not mentioned in this scenario.
Correct: In some cases, diarrhea may be the result of liquid medications such as
elixirs and suspensions that have a very high osmolality.
Incorrect: Diarrhea is not a frequent side effect of ranitidine.
15. A malnourished client is being discharged on enteral nutrition products.
Which suggestion from the registered dietitian does the nurse implement to
make the enteral feeding experience more normal for the client?

A. Administering the feeding product on a regular schedule Incorrect

B. Bringing the enteral product and napkin to the client on a tray
C. Emphasizing the need to take iron medications before the feeding
D. Once feeding is completed, putting equipment out of view: Answer B.

Rationales:
Incorrect: Although the feeding product should be administered according to the
prescribed schedule, this will not necessarily normalize the experience for the
client.
Correct: "Serving" the enteral product and napkin on a tray will help normalize the
feeding experience for the client.
Incorrect: Although iron medications may be helpful in preventing constipation,
encouraging their use will not normalize the experience for the client.
Incorrect: Although putting equipment away after use may be helpful in taking the
client out of the dependent "client" role, this will not serve to normalize the feeding
experience itself.
16. An older adult client needs additional dietary protein but refuses to drink
the prescribed liquid protein supplements. Which nursing intervention is
most effective in increasing the client's protein intake?

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A. Administering the liquid supplement with routine medications Incorrect
B. Giving a glucose polymer modular supplement
C. Keeping a food and fluid intake diary for at least 3 days
D. Providing protein modular supplements in the form of puddings: Answer
D.

Rationales:
Incorrect: This approach will not be effective because the client has already refused
to drink the liquid supplements.
Incorrect: Glucose polymer modular supplements will increase the client's calorie
intake but not protein intake.
Incorrect: A food and fluid diary will provide information about the client's typical
intake pattern but will not increase protein intake.
Correct: Providing protein modular supplements in the form of puddings would
increase the client's protein intake in an alternate format, other than a liquid
supplement.
17. A nurse is instructing a group of overweight clients on the complications
of obesity that develop when weight is not controlled through diet and
exercise. Which lifestyle changes does the nurse emphasize? Select all that
apply.

A. "Begin a weight-training program for building muscle mass."

B. "Consume a diet that is moderate in salt and sugar and low in fats and
cholesterol."
C. "Eat a variety of foods, especially grain products, vegetables, and fruits."
D. "Engage in moderate physical activity for at least 30 minutes each day."
E. "Foods eaten away from home tend to be higher in fat, cholesterol, and
salt and lower in calcium than foods prepared at home."
F. "Liquid dietary supplements can be substituted safely for solid food while
attempting to lose weight.": Answers B, C, D, E

Correct Feedback:
Correct: Consuming a diet that is moderate in salt and sugar and low in fats and
cholesterol is a smart strategy for a person who wants to lose weight.
Correct: Eating a variety of foods, especially grain products, vegetables, and fruits,
helps people achieve weight loss. These are foods that "burn" more calories as
they are metabolized.
Correct: Moderate physical activity for at least 30 minutes each day is a good idea
for people who are trying to be healthy and/or to reduce their weight.
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Correct: True. Many foods eaten away from home tend to be higher in fat, choles-
terol, and salt and lower in calcium than foods prepared at home. When dining
"out," people can make smart choices, but they have to be educated and careful.
18. A nurse is performing a health assessment on an obese client. The client
states, "I have tried many diets in an effort to lose weight but have been
unsuccessful!" How does the nurse assess whether the client's response to
stress is related to the client's obesity?

A. "Do you have a history of mental problems, especially depression?"

B. "Do you usually use alcohol or drugs when you feel stressed?"
C. "Tell me what you do to relieve stress in your daily life."
D. "What is it about your obesity that causes you to feel uncomfortable?": -
Answer C.

Rationales:
Incorrect: This question will cause the client to feel uncomfortable with the as-
sessment. Problems in handling stress do not mean mental health or depression
problems.
Incorrect: This question could cause the client to feel uncomfortable with the
assessment. More effective methods can be used to determine the client's alcohol
and drug habits.
Correct: This is the only question that allows the client to verbalize stress-relieving
mechanisms. It is also a question that cannot be answered with a simple "yes" or
"no."
Incorrect: This question will only cause the client to restate the obvious. It does not
determine the effect that stress has on the client.
19. A young adult man says that he cannot stay on a diet because of trouble
finding one that will incorporate his food preferences. How does the nurse
effectively plan nutritional care for this client?

A. Calculates his body mass index (BMI)

B. Keeps a 24-hour diary of his physical activities
C. Maintains a 24-hour recall (diary) of his food intake
D. Obtains his accurate height and weight measurements: Answer C.

Rationales:
Incorrect: Although calculating a BMI is an important part of a nutritional assess-
ment, it does not address the issue of the client's food preferences.
Incorrect: Keeping an activity diary will not reveal any information related to the
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client's food preferences.
Correct: Maintaining a 24-hour recall of food intake will determine the client's food
preferences and eating patterns so that they can be incorporated into the diet to
the greatest extent possible.
Incorrect: Although measuring height and weight is an important part of a nutritional
assessment, it does not address the issue of the client's food preferences.
20. A client is receiving nutritional supplements to restore nutritional status.
What does the nurse do to assess the effectiveness of the supplements for
the client?

A. Keeps an accurate and precise food and fluid intake record daily
B. Makes certain the client is weighed daily at the same time
C. Monitors vital signs every 4 hours and as needed
D. Weekly assesses the client's skin for evidence(s) of breakdown: Answer B.

Rationales:
Incorrect: Although it is important to identify everything that the client is taking in
orally, this does not help assess the effects of nutritional supplements on the client.
Correct: Daily weigh-ins will best show the effects of nutritional supplements by
showing how much weight the client is regaining.
Incorrect: Although monitoring of vital signs is important, it does not help assess
the effects of nutritional supplements on the client.
Incorrect: Although it is important to identify any evidence of skin breakdown, this
does not directly help in assessing the effects of nutritional supplements on the
client.

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