HESI Altered Nutrition

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1. BOLUS FEEDING D. Ensure that Mr. Rusk

The feedings are changed to bolus feeding 3 times a day. After receiving instruction, Mr. Rusk flushes the tubing with
demonstrates correct ability to perform the skill and states he feels he can handle this responsibility. water after the syringe is
Mr. Rusk is discharged home and home health care services resume. During a home visit, the nurse empty of feeding -
observes Mr. Rusk as he administers a bolus feeding to Mr. Rusk, who is sitting upright in the bed. After
checking the residual volume, Mr. Rusk pours the feeding into the syringe attached to the feeding Rationale: Flushing the
tube. He then holds the syringe upright while the feeding enters the stomach. syringe and tubing with
water reduces the risk
25. In observing this procedure, what action should the nurse take? for obstruction of the
tubing
A. Teach Mr. Rusk to lower the syringe to increase the speed of the feeding
B. Lower the head of the bed until the feeding has all drained from the syringe
C. Remind Mr. Rusk to check for residual again after the feeding has entered the stomach
D. Ensure that Mr. Rusk flushes the tubing with water after the syringe is empty of feeding
2. BOLUS FEEDING 1)B. Tell Mr. Rusk to hold
While Mr. Rusk administers the feeding, Mrs. Rusk tells the nurse that she has had 5 to 7 liquid diarrhea the remaining feeding -
stools a day for the last 2 days.
Rationale: Tube feedings
26. What action should the nurse implement first? may cause diarrhea. The
nurse should first advice
A. Notify the health care provider of the diarrhea Mr. Rusk to hold the
B. Tell Mr. Rusk to hold the remaining feeding remaining feeding until
C. Assess the elasticity of Mrs. Rusk's skin further assessment is
D. Auscultate for the presence of bowel sounds completed
2) D. Auscultate for the
presence of bowel
sounds
3) C. Assess the
elasticity of Mrs. Rusk's
skin
4) A. Notify the health
care provider of the
diarrhea
3. CARE OF CLIENT WITH FEEDING TUBE D. Continue to monitor
Mrs. Rusk returns to her room following the insertion of the PEG tube. She has an IV of Lactated the client without
Ringer's Solution infusing at 50 ml/hour, but does not have any feeding solution attached to the PEG infusing any solution
tube. through the PEG tube -

19. What initial action should the nurse implement? Rationale: Feeding
supplements are
A. Connect the Lactated Ringer's Solution to the PEG tube at the prescribed rate typically initiated when
B. Prepare to infuse water slowly through the PEG tube for the first 8 hours bowel sounds are
C. Call the dietary department and request immediate delivery of the feeding solution present, usually within 24
D. Continue to monitor the client without infusing any solution through the PEG tube hours following PEG
tube insertion.
4. CARE OF CLIENT WITH FEEDING TUBE B. Circle the amount of drainage on the initial dressing -
The nurse observes that the dressing around the PEG tube
insertion site is intact, with a small amount of Rationale: Circling this small amount of drainage allows the nurse to
serasanguineous drainage. compare any changes in the amount of drainage at a later time.

20. What action should the nurse implement?

A. Apply pressure dressing over the initial dressing

B. Circle the amount of drainage on the initial dressing
C. Remove the dressing and apply a new sterile dressing
D. Notify the health care provider of the finding
immediately
5. CLIENT TEACHING C. Determine if Mr. Rusk feels ready to learn the skill -
Over time, the continuous feeding is increased to 80
ml/hour and changed to full strength formula. The nurse Rationale: Readiness to learn is essential for effective teaching. If Mr.
plans to teach Mr. Rusk how to manage the continuous Rusk expresses a lack of readiness to learn, the nurse can obtain
feeding when Mrs. Rusk is discharged. further data, such as information about financial resources, which may
be impacting his readiness to learn.
23. Before beginning the teaching plan, what action is most
important for the nurse to implement?

A. Ask about the couple's financial resources

B. Learn Mrs. Rusk's anticipated discharge date
C. Determine if Mr. Rusk feels ready to learn the skill
D. Obtain information about the couple's educational level
6. CLIENT TEACHING D. Acknowledge the stressful nature of the situation and ask Mr. Rusk
When the nurse demonstrates the use of the feeding if he feels ready to continue -
equipment, Mr. Rusk looks away. The nurse observes that he
is crying. Rationale: This is a therapeutic response, offering support and
allowing Mr. Rusk to feel in control of the situation.
24. What action should the nurse implement?

A. Continue with the demonstration of the equipment while

allowing Mr. Rusk time to control his emotions
B. Reassure Mr. Rusk that management of the feeding
equipment while allowing Mr. Rusk time to control his
emotions
C. Stop the demonstration and leave the room until Mr.
Rusk states he is ready to continue with the teaching
session
D. Acknowledge the stressful nature of the situation and
ask Mr. Rusk if he feels ready to continue
7. DIETARY INSTRUCTION
Mr. Rusk looks at the newly prescribed medication,
which is a brand name drug, and states, "Next time we
fill this prescription, I hope we can get this in a generic
form. Maybe it won't be so expensive."
16. How should the nurse respond?
D. "Your pharmacist and health care provider can determine if there is a
generic drug that is a safe alternative to the brand name drug." -
Rationale: Although brand name and generic medications are
bioequivalent, the inert ingredients may vary, sometimes resulting in
differing effects. Therefore, the health care provider must approve the
substitution of a generic form for a prescribed brand name medication.

A. "You shouldn't worry about the cost of medications

right now; you should purchase whatever your wife
needs to get well."
B. "Brand name medications are generally more
effective than generic drugs, so they are worth the
additional cost."
C. "Brand name drugs and generic drugs are
bioequivalent, so Mrs. Rusk can safely take either form
of the medication."
D. "Your pharmacist and health care provider can
determine if there is a generic drug that is a safe
alternative to the brand name drug."
8. DIETARY INSTRUCTION A. Onset of action -
Mrs. Rusk has a new prescription for an appetite
stimulant. Rationale: The nurse should determine when the drug will start to take
effect, so that the medication can be taken when the greatest therapeutic
15. Before advising Mrs. Rusk when she should take the effect can be achieved.
medication, the nurse should obtain what information
about the drug?

A. Onset of action
B. Therapeutic index
C. Drug half life
D. Bioavailablity
9. DIETARY INSTRUCTION D. Scrambled eggs and sausage -
The health care provider prescribes an appetite
stimulant and asks the nutritionist to consult with the Rationale: Both eggs and sausage are good sources of protein
Rusks regarding Mrs. Rusk's dietary needs.
The nurse and nutritionist collaborate to develop a E. egg, potato, & onion omelet- good source of protein, vitamins and
plan of care to improve Mrs. Rusk's nutritional status. minerals
The nurse teaches the Rusks about foods high in
protein and provides them with sample menus.

13. Which breakfast selection provides the most

protein?

A. Oatmeal with a sliced banana

B. Pancakes with maple syrup
C. Hash browns and an English muffin
D. Scrambled eggs and sausage
E. Egg, potato and onion omelet
10. DIETARY INSTRUCTION C. Provide applesauce since she likes it, along with higher
The nurse also encourages Mrs. Rusk to prepare high calorie snacks calorie snacks -
for Mrs. Rusk. Mr. Rusk states that his wife loves applesauce and asks
if this is a good snack choice. Rationale: To improve the client's nutrition, the nurse needs
to consider the likes and dislikes of the client in addition to
14. How should the nurse respond? the needed nutrients. Combining applesauce, which the
client likes, but which is not a really high calorie snack,
A. Do no offer her applesauce because it does not provide very with snacks which contain more calories, best meets the
many calories needs of the client.
B. Processed foods such as applesauce are often very high in sodium
C. Provide applesauce since she likes it, along with higher calories
snacks
D. Applesauce is an excellent source of nutrients and calories
11. DYSPHAGIA PRECAUTIONS C. Instruct the UAP to add a thickening agent to all liquids
The nurse visits with Mr. Rusk and then observes as the UAP assists -
Mrs. Rusk with her meal. The UAP gives Mrs. Rusk a glass of iced tea
to drink. Rationale: Clients with dysphagia typically have difficulty
swallowing liquids, so a thickening agent is aded to liquids
6. Considering the need for dysphagia precautions, how should the to change the consistency, making swallowing easier.
nurse intervene?

A. Remind the IAP to keep track of the fluid intake and output
B. Advise the UAP to provide all fluids at room temperature
C. Instruct the UAP to add a thickening agent to all liquids
D. Establish a fluid restriction for the UAP to follow
12. DYSPHAGIA PRECAUTIONS D. Bathe the client first and then place the client in a high
The speech therapist is consulted and makes a home visit to evaluate Fowler's position during and after the meal -
Mrs. Rusk. The therapist determines that dysphagia precautions are
needed. The nurse and unlicensed assistive personnel (UAP) arrives Rationale: The head of the bed should be elevated to a
at the home shortly after the therapist's evaluation is completed. The high Fowler's position while the client with dysphagia is
UAP prepares to assist Mrs. Rusk with her noon meal and with her eating, and kept elevated for at least 1 hour following the
personal care. meal to reduce the risk for aspiration

5. What instruction should the nurse provide the UAP?

A. Keep the client in a semi-Fowler's position while bathing her and

also while assisting her with her meal
B. Help feed the client first and then allow her to rest with the head
of the bed lowered for 1 hour before bathing her
C. Provide assistance with the meal and then lower the head of the
bed to bathe the client and change the bed linens
D. Bathe the client first and then place the client in a high Fowler's
position during and after the meal.
13. ETHICAL-LEGAL CONSIDERATIONS D. Advise Mrs. Rusk that an
Mrs. rusk gradually weakens and is admitted to the nearby medical center. Her health care identifying bracelet needs to be
provider recommends the insertion of a feeding tube, by means of a percutaneous secured on her wrist in case an
esophageal gastrostomy (PEG). Mrs. Rusk signs the consent form and the procedure is emergency occurs -
scheduled for the next day. That evening, the nurse notes that Mrs. Rusk's medical record
contains an advanced directive requesting that she not be resuscitated in the event of an Rationale: An identifying wrist
arrest, which is confirmed in the prescriptions written by the health care provider. While bracelet indicating that
conversing with Mr. and Mrs. Rusk, Mr. Rusk confirms that Mrs. rusk has asked that "no heroic resuscitation should not be
measures be taken to save her life." performed helps ensure that the
client's wishes are known and
17. What action should the nurse take? respected.

A. Meet privately with Mrs. Rusk to discuss that a feeding tube can be considered a heroic
means of keeping a client alive
B. Inform Mrs. Rusk that the instructions in her advanced directive cannot be followed if she
has a feeding tube
C. Ask Mrs. Rusk why she wants to have a feeding tube inserted since she has an advanced
directive requesting no heroic measures
D. Advice Mrs. Rusk that an identifying bracelet needs to be secured on her wrist in case an
emergency occurs
14. ETHICAL-LEGAL CONSIDERATIONS A. Provide the couple with privacy
The next morning, the nurse enters Mrs. Rusk's room to prepare her to go to the procedure to discuss the decision -
room. The nurse states that the procedure is scheduled in 30 minutes. Mrs. Rusk, who is still
lethargic from her sleeping pill, tells the nurse she has changed her mind and does not want Rationale: The nurse must address
the procedure performed, stating she would rather just "go ahead and die." Her husband is in the client's expressed desire to
the room, and is very upset by his wife's comment. cancel the procedure. The nurses's
initial actions should include
18. What action should the nurse implement? allowing the couple privacy to
discuss the decision, addressing
A. Provide the couple with privacy to discuss the decision any concerns of the client, and
B. Continue to prepare the client for the scheduled procedure encouraging further
C. Remind the client that the consent form is already signed communication.
D. Ask the client's husband if the procedure should be cancelled
15. FORMULA CALCULATION C. Increase the rate of the formula
After infusing the half strength formula at 40 ml/hour for 6 hours, the nurse checks the to 50 ml/ hour -
clients residual volume and obtains 75 ml. The prescription for the formula states that the
prescription should be increased by 10 ml/hour as long as the client's residual volume is less Rationale: The client has received
that half the previously infused total volume. 240 ml during the previous 6
hours. Half of that volume is 120
22. What action should the nurse implement? ml. The residual volume obtained
was 75 ml. so the rate of formula
A. Decrease the rate of the formula to 30 ml/hour should be increased by 10 ml/hour
B. Maintain the rate of the formula at 40 ml/hour to 50 ml/ hour.
C. Increase the rate of the formula to 50 ml/ hour
D. Increase the rate of the formula to 75 ml/hour
16. FORMULA CALCULATION
The next day, the nurse initiates the feeding prescribed
by health care provider. The prescription is for half
strength formula to infuse at 40 ml/hour. The formula is
available in 8 ounce cans. The nurse is preparing enough
formula for 12 hours.
21. How many cans of formula will the nurse need?
(Enter numerical value only. If rounding is necessary,
round to the whole number.)
17. INTERPROFESSIONAL COLLABORATION
In developing the plan of care, the nurse recognizes
that Mrs. Rusk's dysphagia may impact her fluid and
nutritional status.
1-
Rationale: The nurse needs a total volume of 480 ml (12 hours x
40ml/hour). The prescription is for half strength formula, so the volume
of formula needed is 240 ml (480/2). An 8-ounce can of formula
contains 240 ml (8 ounces x 30 ml/ounce). Therefore, only 1 can of
formula is needed.
B. Speech therapist -
Rationale: Speech therapists have expertise in the evaluation and
management of clients with dysphagia.

3.The nurse plans interventions related to Mrs. Rusk's

dysphagia. Which member of the interdisciplinary team
should the nurse refer Mrs. Rusk?

A. Case manager
B. Speech therapist
C. Registered dietician
D. Geriatric nurse practitioner
18. INTERPROFESSIONAL COLLABORATION C. Occupational therapist -
The nurse recognizes that Mrs. Rusk's right-sided
weakness is also a factor contributing to her risk for Rationale: Occupational therapists have expertise in helping clients
altered nutrition. adapt fine motor movements for the provision of self care.

4. With which member of the interdisciplinary team

should the nurse consult regarding this problem?

A. Bariatrics specialist
B. Clinical nutritionist
C. Occupational therapist
D. Rehabilitation counselor
19. NURSING PROCESS B. Establish goals
2. After establishing priorities, what action should the
nurse take next in developing Mrs. Rusk's plan of care? Rationale: the nurse should first complete assessment, then analyze data
to identify problems, and then establish goals. After goals and expected
A. Analyze data outcomes are established, the nurse plans and implements interventions,
B. Establish goals which are then evaluated to determine if the expected outcomes and
C. Complete an assessment goals were accomplished
D. Implement interventions
20. NURSING PROCESS
The nurse's assessment findings include
right sided weakness, slurred speech, and
dysphagia. The nurse identifies that Mrs.
Rusk is at high risk for several problems.
A. Aspiration -
Rationale: Aspiration, or the entry of foreign substances such as food or fluids into the
lungs, may cause hypoxia or respiratory distress. Therefore, this is the highest priority
in establishing the client's plan of care.

1. In developing the nursing plan of care,

which problem has the highest priority?

A. Aspiration
B. Skin Breakdown
C. Altered nutrition
D. Self care deficit
21. NUTRITIONAL ASSESSMENT A. Instruct the home health aide to weigh the client once a week -
9. In planning care, which intervention
should be included to provide the nurse Rationale: Regular measurement of the client's weight provides a useful measurement
with the most accurate information of client's general nutritional status. Assessment of the client's pattern of weight gain
regarding Mrs. Rusk's ongoing nutritional or loss should be combined with other measures, such as general assessment and
status? dietary evaluation for a thorough picture of the client's nutritional status.

A. Instruct the home health aide to weigh

the client once a week
B. Obtain a prescription to draw a
complete blood count weekly
C. Teach Mrs. Rusk how to measure and
record her abdominal girth every day
D. Advice Mr. Rusk to perform capillary
glucose measurements before every meal
22. NUTRITIONAL ASSESSMENT A. The conjunctival sac is pale in appearance when exposed -
During a home visit a week later, the nurse Rationale: The conjunctival sac should be dark pink. Pallor of any mucous membranes
assesses Mrs. Rusk's nutritional status. may indicate anemia.

7. Which data indicates the need for the C. The skin over the sternum tents when pinched -
nurse to evaluate Mrs. Rusk further for Rationale: This is an unexpected finding. Skin tenting typically indicates a fluid volume
altered nutrition? (Select all the apply.) deficit.

A. The conjunctival sac is pale in E. The lips are dry and cracked -
appearance when exposed Rationale: This is an unexpected finding for someone with adequate nutrition, and
B. Blanching occurs when the fingernail could be a sign of dehydration.
bed is compressed
C. The skin over the sternum tents when
pinched
D. Bowel sounds are auscultated every 5
seconds
E. The lips are dry and cracked
23. NUTRITIONAL ASSESSMENT C. The client's ability to feed herself with her left
The nurse obtains further data regarding Mrs. Rusk's nutritional status. hand -

8. Which data best assesses the client's functional ability related to Rationale: This assessment provides information
nutrition? about the client's functional ability.

A. Amount of groceries the client has in the home

B. Types of food the client has eaten within the last 24 hours
C. The client's ability to feed herself with her left hand
D. The husband's schedule for preparing meals
24. NUTRITIONAL INTAKE C. The client's calculated body mass index -
11. Before notifying the health care provider of the data reported by the
nutritionist, what information is most important for the nurse to obtain? Rationale: The body mass index is calculated based
on the client's height and weight, and provides a
A. Type of vitamin supplement the client is taking picture of the client's current nutritional status
B. Percent of diet composed of carbohydrates regarding over or under nutrition.
C. The clients calculated body mass index
D. Daily fat gram intake by the client
25. NUTRITIONAL INTAKE D. Protein of 5.0 g/dl -
The nurse reports the data about Mrs. Rusk's nutritional status to the health
care provider, who asks the nurse to obtain a blood sample for several lab Rationale: The range for normal serum protein level
tests. The nurse obtains a copy of the lab results the next day. in an adult is 6.4-8.3 g/dl. A level of 5.0 g/dl is low,
and may be an indicator of malnutrition.
12. Which serum lab value reflects Mrs. Rusk's altered nutrition?

A. Sodium of 144 mEq/L

B. Calcium of 9.5 mg/dl
C. Potassium of 3.8 mEq/L
D. Protein of 5.0 g/dl
26. NUTRITIONAL INTAKE C. Mrs Rusk's calorie consumption is insufficient and
Two weeks later, the nurse notes a change in Mrs. Rusk's weight. The nurse will result in weight loss -
consults with the nutritionist, who helps complete a 24-hour calorie count.
The nutritionist reports to the nurse that Mrs. Rusk, who weights 125 pounds Rationale: An average adult requires 20 to 35
and is 67 inches tall, is consuming 800 calories per day. calories per kilogram per day. Mrs. Rusk, who
weights 125 pounds, or 57 kilograms, needs a
10. How should the nurse explain the results of the calorie count to Mr. and minimum of 1140 calories per day to maintain her
Mrs. Rusk? current weight.

A. Mrs. Rusk is taking in more calories than she needs and may gain weight
B. Mrs. Rusk is consuming an adequate number of calories for her height
C. Mrs. Rusk's calorie consumption is insufficient and will result in weight
loss
D. Since Mrs. Rusk's activity is limited, her caloric intake is sufficient to
meet her needs