ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 42 Questions
Question 1 of 5
The nurse is caring for a patient who is malnourished and is receiving parenteral nutrition (PN) containing amino acids and dextrose for the past 24 hours. The nurse observes that about 50 mL remain in the PN container. Which of the following actions is best for the nurse to take?
Correct Answer: B
Rationale: All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.
Question 2 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 3 of 5
The nurse is admitting a patient for electrolyte disorders of unknown etiology. Which of the following findings is most important to report to the health care provider?
Correct Answer: D
Rationale: The low serum potassium level may cause life-threatening cardiac dysrhythmias and potassium supplementation is needed rapidly. The other information also will be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.
Question 4 of 5
The student nurse is caring for a patient who is receiving intermittent tube feedings. Which of the following actions by the student nurse should cause the RN to intervene in the patient's care?
Correct Answer: C
Rationale: The residual volume should be checked every 4 hours, not every hour. Elevating the head of the bed to a minimum of 30 degrees, but preferably 45 degrees, prevents aspiration. With intermittent delivery, the head should remain elevated for 30-60 minutes after feeding. The tube is to be flushed before and after the feeding.
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.