Priority Nursing Actions
A nurse finds a patient with a tracheostomy who is experiencing acute respiratory distress. What is the priority nursing action?
Suction the tracheostomy tube
A complication where ingested foods bypass the stomach too fast and enter the small intestine undigested
Dumping syndrome
What type of malnutrition progresses to weight gain, nutritional toxicity, and sedentary lifestyle?
Excess malnutrition
Obesity is defined as a BMI of:
30 or greater
A patient receiving TPN suddenly experiences chest pain, wheezing, and palpitations. The nurse suspects:
An allergic reaction to lipids
A nurse is caring for a patient receiving a blood transfusion who suddenly develops chills, back pain, and hypotension. What is the first nursing action?
Stop the transfusion immediately
A patient is admitted with RUQ pain, anorexia, dyspepsia, n/v, and rebound tenderness, what is the suspected diagnosis?
gallstones
If someone has insufficient malnutrition what associated symptoms are they at risk for?
-lethargy
-fatigue
-poor wound healing
-prone to infection
Which conditions are commonly associated with obesity?
Hypertension
Coronary artery disease
Sleep apnea
Joint deterioration
What are the long-term effects of TPN?
Enlarged liver and spleen
A nurse sees on the monitor that a patient is in a ventricular tachycardia rhythm at the nurses station, what is the first step when noticing this?
Going to check on the patient to ensure that the monitor is on correctly
Tube inserted during an open cholecystectomy and helps pass bile until edema has decrease
T-tube
zinc, copper, iodine, zinc, and fluoride are all trace minerals. What foods are high in these minerals?
-beef
-pork
-seafood (oysters)
-eggs
-beans
-whole grains
What are the three methods of tube feeding?
Continuous, intermittent, cyclic
Which of the following are indications for TPN?
A) Severe malnutrition when the GI tract is non-functional
B) Intractable vomiting and diarrhea
C) Bowel rest due to surgery or inflammation
A post-op patient suddenly develops tachycardia, hypotension, and a firm, distended abdomen. What is the nurse’s priority action?
Notify the healthcare provider immediately
A worried parent arrives to the ED with their newborn child who was delivered in the home is appearing yellow. The child was born at 0500 yesterday, it is currently 0300 what is the suspected diagnosis?
physiological jaundice
A patient weighs 195lbs using the recommended amount of protein that should be consumed per day how much protein should this patient eat on a daily basis?
78 grams of protein a day (195lbs x 0.4grams)
A nurse checks gastric residuals and finds two consecutive measurements over 200 mL. What should they do?
Hold the feeding and notify the provider
What should the nurse do if a patient develops an air embolism while receiving TPN?
A) Place the patient in Trendelenburg position on their left side
B) Clamp the IV catheter
C) Call the healthcare provider immediately
A patient with a chest tube following a pneumothorax has continuous bubbling in the water seal chamber. What is the most appropriate nursing intervention?
Check the system for an air leak
A patient has been receiving parental nutrition it was started a month ago. Prior to starting it they weighed 145lbs, they now weigh 153lbs. What is the expected action?
There is no action, this is expected.
(1-2 lbs/week)
Name 6 signs and symptoms of insufficient malnutrition?
pallor
fatigue/weakness/periods of lightheadedness
trouble breathing
hair loss
heart palpitations
depression
menstrual issues
constipation
poor wound healing
A tube-fed patient suddenly develops vomiting, coughing, and changes in breathing. What complication is suspected?
Aspiration pneumonia
If a patient’s TPN bag runs out suddenly, what should the nurse do?
Start D10 infusion at the same rate