ATI LPN
Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 24 : Nutritional Care and Support Questions
Question 1 of 5
What intervention(s) should you prepare for when caring for a patient who is 6 hours post burn with 30% seconddegree burns and absent bowel sounds?
Correct Answer: A,B
Rationale: Burns over 20% of total body surface area (TBS
A) can lead to paralytic ileus, where the GI tract temporarily stops moving. Absent bowel sounds suggest the GI system is not functioning properly.
To prevent vomiting, aspiration, or bowel distension, oral intake is withheld. An NG (nasogastric) tube may be inserted to decompress the stomach and reduce the risk of complications.
Question 2 of 5
Which actions are taken to verify the correct placement of a small-bore NG tube immediately after insertion? (Rank your answers in the correct order.)
Order the Items
Source Container
Correct Answer: D,A,B,E,C
Rationale:
To verify the correct placement of a small-bore NG tube immediately after insertion, the first and most important step is to obtain an x-ray, as this is the gold standard for confirming placement and must be completed before administering any feedings or medications. Once placement is confirmed radiographically, the nurse can then aspirate gastric contents, checking the pH (which should be between 1 and 5) and observing the color, which is typically grassy green, tan, or off-white, indicating gastric placement. Next, the nurse should confirm the tube size and ensure it is securely taped in place to prevent displacement. After verification, the nurse may flush the tube with 15 to 30 mL of water to confirm patency, but this is done only after placement is confirmed, not as a method of verification itself. The water bubble test, which involves placing the distal end of the tube in water to check for bubbles, is outdated and unreliable and should not be used in current clinical practice.
Question 3 of 5
You are working in a pediatric clinic when the mother of a 15-year-old female patient calls with concerns about her daughter. Which behaviors she describes would alert you to a possible eating disorder?
Correct Answer: A,C,D
Rationale: Constant weight concern may indicate body image distortion, which is common in eating disorders such as anorexia nervosa. Excessive exercise can be a form of compensatory behavior often seen in both anorexia and bulimia, as individuals attempt to burn off calories consumed. A sore throat and indigestion may result from frequent vomiting, which is a classic sign of bulimia nervosa due to the irritation of the throat and esophagus by stomach acid.
Question 4 of 5
A patient is receiving TPN via a central venous catheter. The patient's wife is concerned about his care and wants to know why the TPN bag is not changed as often as a regular IV bag of solution would be. You respond by telling her the standard for changing the TPN bag is every:
Correct Answer: D
Rationale: TPN bags are typically changed every 24 hours to minimize infection risk and maintain stability of the nutrient solution.
Question 5 of 5
You are caring for a patient who is scheduled for surgery. Your teaching will include information about nutrition and healing. You will tell the patient which of the following macronutrients is required for tissue repair?
Correct Answer: D
Rationale: Protein is essential for tissue repair and wound healing, as it provides amino acids needed for cell regeneration and collagen formation.