ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 42 Questions
Question 1 of 5
The nurse is assessing a patient who is a vegan. Which of the following findings may indicate the need for cobalamin supplementation?
Correct Answer: A
Rationale: Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, megaloblastic anemia, and the neurological signs of cobalamin deficiency. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.
Question 2 of 5
The nurse is admitting a patient with a body mass index (BMI) of 17 kg/m?² and a low albumin level. Which of the following assessment findings should the nurse expect to find?
Correct Answer: C
Rationale: Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.
Question 3 of 5
The nurse is teaching a patient about a high calorie, high protein diet. Which of the following menu choices indicates that the teaching has been effective?
Correct Answer: D
Rationale: Foods that are high in calories include fried foods and those covered with sauces. High protein foods include meat and dairy products. The other choices are lower in calories and protein.
Question 4 of 5
The nurse is caring for a patient with a body mass index (BMI) of 31 kg/m?², a normal C-reactive protein level, and low transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in which of the following?
Correct Answer: B
Rationale: The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.
Question 5 of 5
The nurse has just started a patient on continuous tube feedings of a full-strength commercial formula at 100 mL/hour using a closed system method and has had six diarrhea stools the first day. Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.