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NURX105 Essentials of Nursing Care Health Differences Exam
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NURX105 Essentials of Nursing Care HealthDifferences Exam
Nutrition
What are appropriate expected outcomes for a patient with a BMI of 40 who has the
nursing diagnosis label of Imbalanced Nutrition: More than Body Requirements?
(Select all that apply.)
The patient will lose 1 to 2 pounds per week.
The patient will report a decrease in appetite.
The patient will reduce intake of high-calorie foods.
The patient will verbalize improvement in self-esteem.
The patient will incorporate a physical activity program. - Answer *1) Expected
outcomes for the nursing diagnosis statement of Imbalanced Nutrition: more than body
requirements include the patient stating factors that contribute to weight gain, losing
weight in a reasonable period of time (1 to 2 pounds per week), dietary modifications
(eat fewer high-calorie foods), and incorporate activities that require energy
expenditure (physical activity).
2) A decrease in appetite is not related to Imbalanced Nutrition: More Than Body
Requirements.
*3) See 1).
4) An improvement in self-esteem is not related to Imbalanced Nutrition: More Than
Body Requirements.
,*5) See 1).
Nutrition
A patient is receiving liquid nutrients at 60 mL/hr via nasogastric tube. The RN
determines that there is a gastric residual of 60 mL of liquid. Which action by the RN is
the most important nursing intervention?
Auscultate bowel sounds.
Continue the tube feeding.
Discard the residual liquid.
Assess for abdominal distention. - Answer 1) Presence of bowel sounds will not impact
the feeding.
*2) The residual volume is within acceptable guidelines.
3) The residual fluid contains electrolytes and should be fed to he patient..
4) Abdominal distention might be present if the patient is not tolerating their feedings,
but monitoring the absorption is most important.
Nutrition
An RN collects the following data from a 65-year-old patient who lives alone: height
5'10" (178 cm); weight 128 lb (58 kg); a BMI of 18.4; eats 2 meals a day consisting of
cereal and milk for breakfast and a tuna sandwich and coffee for dinner; reports having
a bowel movement every 3 days. Which nursing diagnosis label is most applicable?
Imbalanced Nutrition: Less Than Body Requirements
, Constipation
Ineffective Health Maintenance
Social Isolation - Answer *1) The BMI for this patient is 18.4 which is underweight.
2) Although a bowel movement every three days could be a sign of constipation, given
what the patient is eating, it is normal.
3) Ineffective Health Maintenance is a possibility given that the patient is not consuming
a healthy diet for height and weight. However, critical defining characteristics to
support this diagnosis label are missing.
4) Just because the patient lives alone, it is not correct for the RN to assume that the
patient is socially isolated. Important defining characteristics to support this diagnosis
label are missing.
Nutrition
An RN is developing a teaching plan for a caregiver of a patient who will be discharged
with a gastrostomy tube. Which action should the RN include in the teaching plan?
The tube is flushed only after medication is given.
An empty feeding bag remains attached to the tubing.
The reusable equipment is washed with soap and water.
The tube is replaced on a weekly basis. - Answer 1) The tube should be flushed with
room-temperature water before and after each feeding to check patency and clear any
food particles left in the tubing.
2) An empty feeding bag can provide a growth environment for microorganisms.
*3) It is important to thoroughly wash reusable equipment to prevent the spread of
infection.
, 4) Gastrostomy tubes may be temporary or permanent. In either case, removal of the
tube is performed by medical personnel, not by the patient or caregiver.
Nutrition
An RN is preparing a nasogastric tube insertion. Which measurement does the RN use
to estimate the insertion depth when inserting this NGT into the patient?
The distance from the mouth to the end of the xiphoid process
The distance from the nose to the earlobe to the end of the sternum
The distance from the tip of the nose to the sternal manubrial angle
The distance from the tip of the earlobe to the top of the sternum - Answer 1) This
measurement is too short. It does not take into account the length needed for the nares.
*2) When inserting a nasogastric tube, the RN should measure the distance from the tip
of the patient's nose to the tip of the earlobe and then from the tip of the earlobe to the
end of the sternum. This length approximates the distance from the nares to the
stomach.
3) This measurement is too short. It does not take into account the length of the
esophagus or the nasopharynx.
4) This measurement is too short. It does not take into account the length needed for the
nasal passage.
Nutrition
A parent brings a 15-month-old child to the pediatrician's office for a routine visit and
expresses concern that her appetite has significantly decreased. Which factor would
the RN explain as most likely accounting for this toddler's sudden decrease in appetite?
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