Hinkle 41 Flashcards
A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function?
A. Use glycerin suppositories on a regular basis.
B. Limit physical activity in order to promote bowel peristalsis.
C. Consume high-residue, high-fiber foods.
D. Resist the urge to defecate until the urge becomes intense.
ANS: C
Rationale: Goals for the client include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.
The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client’s stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse’s best action?
A. Contact the care provider to have the client’s hemoglobin and hematocrit measured.
B. Document these expected assessment findings.
C. Apply barrier ointment to the stoma as prescribed.
D. Cleanse the stoma with alcohol or chlorhexidine.
ANS: B
Rationale: Redness and slight bleeding are expected, so no further intervention or assessment is likely necessary.
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse’s rapid assessment reveals that the client’s abdomen is uncharacteristically rigid on palpation. What is the nurse’s best response?
A. Administer a Fleet enema as prescribed and remain with the client.
B. Contact the primary care provider promptly and report these signs of perforation.
C. Position the client supine and insert an NG tube.
D. Page the primary provider and report that the client may be obstructed.
ANS: B
Rationale: The client’s change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority.
A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
A. Insertion of a nasogastric tube
B. Insertion of a central venous catheter
C. Administration of a mineral oil enema
D. Administration of a glycerin suppository and an oral laxative
ANS: A
Rationale: Decompression of the bowel through a nasogastric tube is necessary for all clients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.
A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client’s care, which of the following nursing diagnoses should the nurse prioritize?
A. Ineffective tissue perfusion related to bowel ischemia
B. Imbalanced nutrition: Less than body requirements related to impaired absorption
C. Anxiety related to bowel obstruction and subsequent hospitalization
D. Impaired skin integrity related to bowel obstruction
ANS: A
Rationale: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.
A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite?
A. High levels of alcohol consumption
B. History of bowel obstruction
C. History of diverticulitis
D. Longstanding psychosocial stress
ANS: A
Rationale: Risk factors include high alcohol intake; cigarette smoking; and high-fat, high-protein, low-fiber diet. Diverticulitis, obstruction, and stress are not noted as risk factors for colorectal cancer
A client’s screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client’s health problem?
A. Adherence to a high-fiber diet will help the polyps resolve.
B. The client should be assured that this is a normal, age-related physiologic change.
C. The client’s polyps constitute a risk factor for cancer.
D. The presence of polyps is associated with an increased risk of bowel obstruction.
ANS: C
Rationale: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions.
A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids?
A. A 45-year-old teacher who stands for 6 hours per day
B. A pregnant woman at 28 weeks’ gestation
C. A 37-year-old construction worker who does heavy lifting
D. A 60-year-old professional who is under stress
ANS: B
Rationale: Hemorrhoids commonly affect 50% of clients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.
An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform?
A. Encourage the client to take stool softener daily.
B. Assess the client’s food and fluid intake.
C. Assess the client’s surgical history.
D. Encourage the client to take fiber supplements.
ANS: B
Rationale: The nurse should follow the nursing process and perform an assessment prior to interventions. The client’s food and fluid intake is more likely to affect bowel function than surgery.
A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client’s nursing care, the nurse should prioritize what nursing diagnosis?
A. Imbalanced nutrition: Less than body requirements related to decreased oral intake
B. Risk for infection related to possible rupture of appendix
C. Constipation related to decreased bowel motility and decreased fluid intake
D. Chronic pain related to appendicitis
ANS: B
Rationale: The client with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.
A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate?
A. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy.
B. Provide the client with educational materials that match the client’s learning style.
C. Encourage the client to write down these concerns and questions to bring forward to the surgeon.
D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.
ANS: D
Rationale: A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with the selection of an appropriate stoma site, teach about stoma care, and provide emotional support. The surgeon is less likely to address the client’s psychosocial and learning needs. Reassurance does not address the client’s questions, and education may or may not alleviate anxiety.
The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client’s health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis?
A. Recurrent constipation coupled with weight loss
B. Foul-smelling diarrhea that contains fat
C. Fever accompanied by a rigid, tender abdomen
D. Bloody bowel movements accompanied by fecal incontinence
ANS: B
Rationale: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.
A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse’s priority action?
A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse.
B. Report signs and symptoms of obstruction to the health care provider.
C. Encourage the client to mobilize in order to enhance motility.
D. Contact the health care provider and obtain a swab of the stoma for culture.
ANS: B
Rationale: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma because infection is unrelated to this problem.
A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client’s care, the nurse should collaborate with the client and prioritize what goal?
A. Client will accurately identify foods that trigger symptoms.
B. Client will demonstrate appropriate care of his ileostomy.
C. Client will demonstrate appropriate use of standard infection control
precautions.
D. Client will adhere to recommended guidelines for mobility and activity.
ANS: A
Rationale: A major focus of nursing care for the client with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the client than managing physical activity.
A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion?
A. Annual screening colonoscopies
B. Adherence to recommended immunization schedules
C. Regular blood pressure monitoring
D. Frequent screening for osteoporosis
ANS: D
Rationale: Persons with lactose intolerance often experience hypocalcemia and a consequent risk of osteoporosis related to malabsorption of calcium. Lactose intolerance does not create an increased need for screening for colorectal cancer, immunizations, or blood pressure monitoring.
An older adult has a diagnosis of Alzheimer disease and has recently been
experiencing fecal incontinence. However, the nurse has observed no recent change in
the character of the client’s stools. What is the nurse’s most appropriate intervention?
A. Keep a food diary to determine the foods that exacerbate the client’s symptoms.
B. Provide the client with a bland, low-residue diet.
C. Toilet the client on a frequent, scheduled basis.
D. Liaise with the primary provider to obtain an order for loperamide.
ANS: C
Rationale: Because the client’s fecal incontinence is most likely attributable to cognitive
decline, frequent toileting is an appropriate intervention. Loperamide is unnecessary in
the absence of diarrhea. Specific foods are not likely to be a cause of, or solution to, this
client’s health problem.
An adult client has been diagnosed with diverticular disease after ongoing challenges
with constipation. The client will be treated on an outpatient basis. What components of
treatment should the nurse anticipate? Select all that apply.
A. Anticholinergic medications
B. Increased fiber intake
C. Enemas on alternating days
D. Reduced fat intake
E. Fluid reduction
ANS: B, D
Rationale: Clients whose diverticular disease does not warrant hospital treatment often
benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated,
and fluid intake is encouraged.
A client’s health history is suggestive of inflammatory bowel disease. Which of the
following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the
client’s signs and symptoms?
A. A pattern of distinct exacerbations and remissions
B. Severe diarrhea
C. An absence of blood in stool
D. Involvement of the rectal mucosa
ANS: C
Rationale: Bloody stool is far more common in cases of UC than in Crohn disease. Rectal
involvement is nearly 100% in cases of UC (versus 20% in Crohn) and clients with UC
typically experience severe diarrhea. UC is also characterized by a pattern of remissions
and exacerbations, while Crohn disease often has a more prolonged and variable course.
During a client’s scheduled home visit, an older adult client has stated to the
community health nurse that the client has been experiencing hemorrhoids of increasing
severity in recent months. The nurse should recommend which of the following?
A. Regular application of an OTC antibiotic ointment
B. Increased fluid and fiber intake
C. Daily use of OTC glycerin suppositories
D. Use of an NSAID to reduce inflammation
ANS: B
Rationale: Hemorrhoid symptoms and discomfort can be relieved by good personal
hygiene and by avoiding excessive straining during defecation. A high-residue diet that
contains fruit and bran along with an increased fluid intake may be all the treatment that
is necessary to promote the passage of soft, bulky stools to prevent straining. Antibiotics,
regular use of suppositories, and NSAIDs are not recommended, as they do not address
the etiology of the health problem.
A nurse is providing care for a client whose recent colostomy has contributed to a
nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention
best addresses this diagnosis?
A. Encourage the client to conduct online research into colostomies.
B. Engage the client in dialogue about the implications of having the colostomy.
C. Emphasize the fact that the colostomy was needed to alleviate a much more
serious health problem.
D. Emphasize the fact that the colostomy is temporary measure and is not
permanent.
ANS: B
Rationale: For many clients, being able to dialogue frankly about the effect of the ostomy
with a nonjudgmental nurse is helpful. Emphasizing the benefits of the intervention is
unlikely to improve the client’s body image, since the benefits are likely already known.
Online research is not likely to enhance the client’s body image and some ostomies are
permanent.
The nurse is providing care for a client whose inflammatory bowel disease has
necessitated hospital treatment. Which of the following would most likely be included in
the client’s medication regimen?
A. Antidiarrheal medications 30 minutes before a meal
B. Antiemetics on a PRN basis
C. Vitamin B12 injections to prevent pernicious anemia
D. Beta adrenergic blockers to reduce bowel motility
ANS: A
Rationale: The nurse administers antidiarrheal medications 30 minutes before a meal as
prescribed to decrease intestinal motility and administers analgesics as prescribed for
pain. Antiemetics, vitamin B12 injections and beta blockers do not address the signs,
symptoms, or etiology of inflammatory bowel disease.
A client’s colorectal cancer has necessitated a hemicolectomy with the creation of a
colostomy. In the 4 days since the surgery, the client has been unwilling to look at the
ostomy or participate in any aspects of ostomy care. What is the nurse’s most
appropriate response to this observation?
A. Ensure that the client knows that he or she will be responsible for care after discharge.
B. Reassure the client that many people are fearful after the creation of an ostomy.
C. Acknowledge the client’s reluctance and initiate discussion of the factors underlying it.
D. Arrange for the client to be seen by a social worker or spiritual advisor.
ANS: C
Rationale: If the client is reluctant to participate in ostomy care, the nurse should attempt
to dialogue about this with the client and explore the factors that underlie it. It is
presumptive to assume that the client’s behavior is motivated by fear. Assessment must
precede referrals and emphasizing the client’s responsibilities may or may not motivate
the client.
A nurse is caring for an older adult who has been experiencing severe Clostridium
difficile-related diarrhea. When reviewing the client’s most recent laboratory tests, the
nurse should prioritize what finding?
A. White blood cell level
B. Creatinine level
C. Hemoglobin level
D. Potassium level
ANS: D
Rationale: In elderly clients, it is important to monitor the client’s serum electrolyte levels
closely. Diarrhea is less likely to cause an alteration in white blood cell, creatinine, and
hemoglobin levels.
A nurse is assessing a client’s stoma on postoperative day 3. The nurse notes that the
stoma has a shiny appearance and a bright red color. How should the nurse best respond
to this assessment finding?
A. Irrigate the ostomy to clear a possible obstruction.
B. Contact the primary care provider to report this finding.
C. Document that the stoma appears healthy and well perfused.
D. Document a nursing diagnosis of Impaired Skin Integrity.
ANS: C
Rationale: A healthy, viable stoma should be shiny and pink to bright red. This finding
does not indicate that the stoma is blocked or that skin integrity is compromised.
A client has been diagnosed with a small bowel obstruction and has been admitted to
the medical unit. The nurse’s care should prioritize which of the following outcomes?
A. Preventing infection
B. Maintaining skin and tissue integrity
C. Preventing nausea and vomiting
D. Maintaining fluid and electrolyte balance
ANS: D
Rationale: All of the listed focuses of care are important for the client with a small bowel
obstruction. However, the client’s risk of fluid and electrolyte imbalances is an immediate
threat to safety, and is a priority in nursing assessment and interventions.
A client with a diagnosis of colon cancer is 2 days’ postoperative following bowel
resection and anastomosis. The nurse has planned the client’s care in the knowledge of
potential complications. What assessment should the nurse prioritize?
A. Close monitoring of temperature
B. Frequent abdominal auscultation
C. Assessment of hemoglobin, hematocrit, and red blood cell levels
D. Palpation of peripheral pulses and leg girth
ANS: B
Rationale: After bowel surgery, it is important to frequently assess the abdomen,
including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption
of bowel motility is a priority over each of the other listed assessments, even though each
should be performed by the nurse. Obstruction can develop more quickly than infection in
most cases.
A nurse at an outpatient surgery center is caring for a client who had a hemorrhoidectomy. What discharge education topics should the nurse address with this
client?
A. The appropriate use of antibiotics to prevent postoperative infection
B. The correct procedure for taking a sitz bath
C. The need to eat a low-residue, low-fat diet for the next 2 weeks
D. The correct technique for keeping the perianal region clean without the use of water
ANS: B
Rationale: Sitz baths are usually indicated after perianal surgery. A low-residue, low-fat
diet is not necessary and water is used to keep the region clean. Postoperative antibiotics
are not routinely prescribed.
Which of the following is the most plausible nursing diagnosis for a client whose
treatment for colon cancer has necessitated a colostomy?
A. Risk for unstable blood glucose due to changes in digestion and absorption
B. Unilateral neglect related to decreased physical mobility
C. Risk for excess fluid volume related to dietary changes and changes in absorption
D. Ineffective sexuality patterns related to changes in self-concept
ANS: D
Rationale: The presence of an ostomy frequently has an effect on sexuality; this should
be addressed thoughtfully in nursing care. None of the other listed diagnoses reflects the
physiologic changes that result from colorectal surgery.
A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis
of ulcerative colitis. When planning family assessment, the nurse should recognize that
which of the following factors will likely have the greatest impact on the client’s coping
after discharge?
A. The family’s ability to take care of the client’s special diet needs
B. The family’s ability to monitor the client’s changing health status
C. The family’s ability to provide emotional support
D. The family’s ability to manage the client’s medication regimen
ANS: C
Rationale: Emotional support from the family is key to the client’s coping after discharge.
A 21-year-old would be expected to self-manage the prescribed medication regimen and
the family would not be primarily responsible for monitoring the client’s health status. It
is highly beneficial if the family is willing and able to accommodate the client’s dietary
needs, but emotional support is paramount and cannot be solely provided by the client
alone.
A client is scheduled for the creation of a continent ileostomy. What dietary guidelines
should the nurse encourage during the weeks following surgery?
A. A minimum of 30 g of soluble fiber daily
B. Increased intake of free water and clear juices
C. High intake of strained fruits and vegetables
D. A high-calorie, high-residue diet
ANS: C
Rationale: A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and
vegetables are given. These foods are important sources of vitamins A and C. Adequate
fluid intake is important, but it does not need to be particularly high. High fiber intake
would lead to complications.
A client has been experiencing occasional episodes of constipation and has been
unable to achieve consistent relief by increasing physical activity and improving the
client’s diet. When introducing the client to the use of laxatives, what teaching should the
nurse emphasize?
A. The effect of laxatives on electrolyte levels
B. The underlying causes of constipation
C. The risk of fecal incontinence
D. The risk of becoming laxative-dependent
ANS: D
Rationale: Laxatives should not normally be used on an ongoing basis because of the risk
of dependence. In most cases they have a minimal effect on electrolyte levels. A client
who has increased activity and improved diet likely has an understanding of the usual
causes of constipation. Excessive laxative use could lead to diarrhea or fecal
incontinence, but for most clients the risk of dependence is more significant.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent
surgery for gastric cancer. Which of the nurse’s assessments most directly addresses a
major complication of TPN?
A. Checking the client’s capillary blood glucose levels regularly
B. Having the client frequently rate his or her hunger on a 10-point scale
C. Measuring the client’s heart rhythm at least every 6 hours
D. Monitoring the client’s level of consciousness each shift
ANS: A
Rationale: The solution, used as a base for most TPN, consists of a high dextrose
concentration and may raise blood glucose levels significantly, resulting in
hyperglycemia. This is a more salient threat than hunger, though this should be
addressed. Dysrhythmias and decreased LOC are not among the most common
complications.
A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse
knows this client should be started on parenteral nutrition (PN) after what indications?
A. 5% deficit in body weight compared to pre-illness weight and increased caloric need
B. Calorie deficit and muscle wasting combined with low electrolyte levels
C. Inability to take in adequate oral food or fluids within 7 days
D. Significant risk of aspiration coupled with decreased level of consciousness
ANS: C
Rationale: The indications for PN include an inability to ingest adequate oral food or fluids
within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and
aspiration indicate a need for nutritional support, but this does not necessary have to be
parenteral.
A nurse is preparing to administer a client’s intravenous fat emulsion simultaneously
with parenteral nutrition (PN). What principle should guide the nurse’s action?
A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.
B. The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN.
C. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter.
D. The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.
ANS: A
Rationale: Intravenous fat emulsions may be infused simultaneously with PN through a
Y-connector close to the infusion site and should not be filtered. The client does not need
another intravenous line for the fat emulsion. The IVFE cannot be piggy-backed into any
existing IV solution that is infusing.
A nurse is initiating parenteral nutrition (PN) to a postoperative client who has
developed complications. The nurse should initiate therapy by performing which of the
following actions?
A. Starting with a rapid infusion rate to meet the client’s nutritional needs as quickly as possible
B. Initiating the infusion slowly and monitoring the client’s fluid and glucose tolerance
C. Changing the rate of administration every 2 hours based on serum electrolyte values
D. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body
ANS: B
Rationale: PN solutions are initiated slowly and advanced gradually each day to the
desired rate as the client’s fluid and glucose tolerance permits. The formulation of the PN
solutions is calculated carefully each day to meet the complete nutritional needs of the
individual client based on clinical findings and laboratory data. It is not infused more
quickly at mealtimes.
A nurse is caring for a client who has an order to discontinue the administration of
parenteral nutrition. What should the nurse do to prevent the occurrence of rebound
hypoglycemia in the client?
A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.
B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN.
C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN.
D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.
ANS: A
Rationale: After administration of the PN solution is gradually discontinued, an isotonic
dextrose solution is given for 1 to 2 hours to protect against rebound hypoglycemia. The
other listed actions would likely cause hyperglycemia.
A nurse is caring for a client with a subclavian central line who is receiving parenteral
nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the
nurse prioritize?
A. Risk for activity intolerance related to the presence of a subclavian catheter
B. Risk for infection related to the presence of a subclavian catheter
C. Risk for functional urinary incontinence related to the presence of a subclavian
catheter
D. Risk for sleep deprivation related to the presence of a subclavian catheter
ANS: B
Rationale: The high glucose content of PN solutions makes the solutions an idea culture
media for bacterial and fungal growth, and the central venous access devices provide a
port of entry. Prevention of infection is consequently a high priority. The client will
experience some inconveniences with regard to toileting, activity, and sleep, but the
infection risk is a priority over each of these.
A nurse is creating a care plan for a client who is receiving parenteral nutrition. The
client’s care plan should include nursing action(s) relevant to what potential
complications? Select all that apply.
A. Dumping syndrome
B. Clotted or displaced catheter
C. Pneumothorax
D. Hyperglycemia
E. Line sepsis
ANS: B, C, D, E
Rationale: Common complications of PN include a clotted or displaced catheter,
pneumothorax, hyperglycemia, and infection from the venous access device (line
sepsis). Dumping syndrome applies to enteral nutrition, not PN.
A nurse is caring for a client who is receiving parenteral nutrition. When writing this
client’s plan of care, which of the following nursing diagnoses should be included?
A. Risk for peripheral neurovascular dysfunction related to catheter placement
B. Ineffective role performance related to parenteral nutrition
C. Bowel incontinence related to parenteral nutrition
D. Chronic pain related to catheter placement
ANS: B
Rationale: The limitations associated with PN can make it difficult for clients to maintain
their usual roles. PN does not normally cause bowel incontinence and catheters are not
associated with chronic pain or neurovascular dysfunction.
A nurse is aware of the high incidence of catheter-related bloodstream infections in
clients receiving parenteral nutrition. What nursing action has the greatest potential to
reduce catheter-related bloodstream infections?
A. Use clean technique and wear a mask during dressing changes.
B. Change the dressing no more than weekly.
C. Apply antibiotic ointment around the site with each dressing change.
D. Irrigate the insertion site with sterile water during each dressing change.
ANS: B
Rationale: CVAD dressings are changed every 7 days unless the dressing is damp,
bloody, loose, or soiled, in which case they should be changed more often. Sterile
technique (not clean technique) is used. Irrigation and antibiotic ointments are not
normally used.
A nurse is preparing to discharge a client home on parenteral nutrition. What should
an effective home care teaching program address? Select all that apply.
A. Preparing the client to troubleshoot for problems
B. Teaching the client and family strict aseptic technique
C. Teaching the client and family how to set up the infusion
D. Teaching the client to flush the line with sterile water
E. Teaching the client when it is safe to leave the access site open to air
ANS: A, B, C
Rationale: An effective home care teaching program prepares the client to store
solutions, set up the infusion, change the dressings, and troubleshoot for problems. The
most common complication is sepsis. Strict aseptic technique is taught for hand
hygiene, handling equipment, changing the dressing, and preparing the solution. Tap water is
never used for flushes and the access site must never be left open to air.
