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.

1.
In developing the nursing plan of care, which problem has the highest priority?
A) Aspiration.
CORRECT
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.
B) Skin breakdown.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
C) Altered nutrition.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
D) Self care deficit.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.

2.
After establishing priorities, what action should the nurse take next in developing Mrs. Rusk's plan of care?
A) Analyze data.
INCORRECT
The data is analyzed prior to identifying the problems.
B) Establish goals.
CORRECT
The nurse should first complete the assessment, analyze the assessed data to identify problems, and then establish
goals. After the goals and expected outcomes are established, the nurse plans and implements interventions, which
are then evaluated to determine if the expected outcomes and goals were accomplished.
C) Complete an assessment.
INCORRECT
The assessment is completed prior to identifying the problems.
D) Implement interventions.
INCORRECT
Another step should be completed before implementing interventions. This step will come after goals are set.

Interdisciplinary Collaboration
In developing the plan of care, the nurse recognizes that Mrs. Rusk's dysphagia may impact her fluid and
nutritional status.

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.

INCORRECT
The case manager often directs the overall care for clients, but does not have expertise in the specific management
of clients with dysphagia.
B) Speech therapist.
CORRECT
Speech therapists have expertise in the evaluation and management of clients with dysphagia.
C) Registered dietician.
INCORRECT
The registered dietician has expertise in dietary management, but is not the best interdisciplinary team member to
evaluate and plan care for the client with dysphagia.
D) Geriatric nurse practitioner.
INCORRECT
The nurse practitioner has expertise in the overall management of the needs of the geriatric client, but is not the
best interdisciplinary team member to evaluate and plan care for the client with dysphagia.

The nurse recognizes that Mrs. Rusk's right-sided weakness is also a factor contributing to her risk for altered
nutrition.

4.
With which member of the interdisciplinary team should the nurse consult regarding this problem?
A) Bariatrics specialist.
INCORRECT
Bariatrics is a field of health care which deals with the problems of clients who are overweight.
B) Clinical nutritionist.
INCORRECT
Nutritionists have expertise in dietary management.
C) Occupational therapist.
CORRECT
Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self care.
D) Rehabilitation counselor.
INCORRECT
Rehabilitation counselors have expertise in assisting clients manage and cope with their disabilities.

Dysphagia Precautions
The speech therapist is consulted and makes a home visit to evaluate Mrs. Rusk. The therapist determines that
dysphagia precautions are needed. The nurse and unlicensed assistive personnel (UAP) arrive at the home shortly
after the therapist's evaluation is completed. The UAP prepares to assist Mrs. Rusk with her noon meal and with her
personal care.

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.
INCORRECT
This positioning places the client at risk for aspiration.

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.
INCORRECT
This positioning places the client at risk for aspiration.
C) Provide assistance with the meal and then lower the head of the bed to bathe the client and change the bed
linens.
INCORRECT
This positioning places the client at risk for aspiration.
D) Bathe the client first and then place the client in a high Fowler's position during and after the meal.
CORRECT
The head of the bed should be elevated to a high Fowler's position while the client with dysphagia is eating, and
kept elevated for at least 1 hour following the meal to reduce the risk for aspiration.

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.

6.
Considering the need for dysphagia precautions, how should the nurse intervene?
A) Remind the UAP to keep track of the fluid intake and output.
INCORRECT
Maintaining a record of fluid intake and output is not essential in the home care of the client with dysphagia, unless
there is a specific concern regarding fluid balance.
B) Advise the UAP to provide all fluids at room temperature.
INCORRECT
Fluids do not need to be at room temperature for the client with dysphagia.
C) Instruct the UAP to add a thickening agent to all liquids.
CORRECT
Clients with dysphagia typically have difficulty swallowing liquids, so a thickening agent is added to liquids to
change the consistency, making swallowing easier.
D) Establish a fluid restriction for the UAP to follow.
INCORRECT
Liquids are important to maintain an adequate fluid balance and can be provided safely if correct precautions are
implemented.

Nutritional Assessment
During a home visit a week later, the nurse assesses Mrs. Rusk's nutritional status.

7.
Which data indicates the need for the nurse to evaluate Mrs. Rusk further for altered nutrition? (Select all that
apply.)
A) The conjunctival sac is pale in appearance when exposed.
CORRECT
The conjunctival sac should be dark pink. Pallor of any mucous membranes may indicate anemia.
B) Blanching occurs when the fingernail bed is compressed.

INCORRECT
This is an expected finding.
C) The skin over the sternum tents when pinched.
CORRECT
This is an unexpected finding. Skin tenting typically indicates a fluid volume deficit.
D) Bowel sounds are auscultated every 5 seconds.
INCORRECT
This is an expected finding.
E) The lips are dry and cracked.
CORRECT
This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration.

The nurse obtains further data regarding Mrs. Rusk's nutritional status.

8.
Which data best assesses the client's functional ability related to nutrition?
A) Amount of groceries the client has in the home.
INCORRECT
This assessment provides useful information, but is not related to the client's functional ability.
B) Types of food the client has eaten within the last 24 hours.
INCORRECT
This assessment provides useful information, but is not related to the client's functional ability.
C) The client's ability to feed herself with her left hand.
CORRECT
This assessment provides information about the client's functional ability.
D) The husband's schedule for preparing meals.
INCORRECT
This assessment provides useful information, but is not related to the client's functional ability.

9.
In planning care, which intervention should be included to provide the nurse with the most accurate information
regarding Mrs. Rusk's ongoing nutritional status?
A) Instruct the home health aide to weigh the client once a week.
CORRECT
Regular measurement of the client's weight provides a useful measurement of the client's general nutritional
status. Assessment of the client's pattern of weight gain or loss should be combined with other measures, such as
general assessment and dietary evaluation for a thorough picture of the client's nutritional status.
B) Obtain a prescription to draw a complete blood count weekly.
INCORRECT
A complete blood count includes a hemoglobin measurement, an indicator of anemia, but does not provide useful
data about overall nutritional status.
C) Teach Mrs. Rusk how to measure and record her abdominal girth every day.
INCORRECT
Daily measurement of abdominal girth does not provide useful information about nutritional status.
D) Advise Mr. Rusk to perform capillary glucose measurements before every meal.
INCORRECT

Capillary glucose measurements provide useful data about glycemic control in the diabetic, but are not useful in
ongoing assessment of a client's overall nutritional status.

Nutritional Intake
Two weeks later, the nurse notes a change in Mrs. Rusk's weight. The nurse consults with the nutritionist, who
helps complete a 24-hour calorie count. The nutritionist reports to the nurse that Mrs. Rusk, who weighs 125
pounds and is 67 inches tall, is consuming 800 calories per day.

10.
How should the nurse explain the results of the calorie count to Mr. and Mrs. Rusk?
A) Mrs. Rusk is taking in more calories than she needs and may gain weight.
INCORRECT
This is an incorrect analysis of the data.
B) Mrs. Rusk is consuming an adequate number of calories for her height.
INCORRECT
This is an incorrect analysis of the data.
C) Mrs. Rusk's calorie consumption is insufficient and will result in weight loss.
CORRECT
An average adult requires 20 to 35 calories per kilogram per day. Mrs. Rusk, who weighs 125 pounds, or 57
kilograms, needs a minimum of 1140 calories per day to maintain her current weight.
D) Since Mrs. Rusk's activity is limited, her caloric intake is sufficient to meet her needs.
INCORRECT
This is an incorrect analysis of the data.

11.
Before notifying the health care provider of the data reported by the nutritionist, what information is most
important for the nurse to obtain?
A) Type of vitamin supplement the client is taking.
INCORRECT
This information may be useful, but is not the most important information to report to the health care provider.
B) Percent of diet composed of carbohydrates.
INCORRECT
This information may be useful, but is not the most important information to report to the health care provider.
C) The client's calculated body mass index.
CORRECT
The body mass index is calculated based on the client's height and weight, and provides a picture of the client's
current nutritional status regarding over or under nutrition.
D) Daily fat gram intake by the client.
INCORRECT
This information may be useful, but is not the most important information to report to the healthcare provider.

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 tests. The nurse obtains a copy of the lab results the next day.

12.
Which serum lab value reflects Mrs. Rusk's altered nutrition?
A) Sodium of 144 mEq/L.
INCORRECT
This is a normal serum sodium level.
B) Calcium of 9.5 mg/dl.
INCORRECT
This is a normal serum calcium level.
C) Potassium of 3.8 mEq/L.
INCORRECT
This is a normal serum potassium level.
D) Protein of 5.0 g/dl.
CORRECT
The range for normal serum protein level 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.

The health care provider prescribes an appetite stimulant and asks the nutritionist to consult with the Rusks
regarding Mrs. Rusk's dietary needs.

Dietary Instruction
The nurse and nutritionist collaborate to develop a plan of care to improve Mrs. Rusk's nutritional status. 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.
INCORRECT
Oatmeal and bananas are not good sources of protein. The small amount of milk that might be used in the oatmeal
provides some protein.
B) Pancakes with maple syrup.
INCORRECT
Pancakes and syrup are high in carbohydrates, but are not good sources of protein.
C) Hash browns and an English muffin.
INCORRECT
Hash browns and English muffins are not good sources of protein.
D) Scrambled eggs and sausage.
CORRECT
Both eggs and sausage are good sources of protein.

The nurse also encourages Mr. Rusk to prepare high calorie snacks for Mrs. Rusk. Mr. Rusk states that his wife loves

applesauce and asks if this is a good snack choice.

14.
How should the nurse respond?
A) Do not offer her applesauce because it does not provide very many calories.
INCORRECT
This response, though true regarding applesauce as a nutritional food source, is not holistic. It is important to
consider a client's likes when they have a nutritional deficit.
B) Processed foods such as applesauce are often very high in sodium.
INCORRECT
Some processed foods, such as canned soups, are often very high in sodium, but applesauce is not high in sodium.
C) Provide applesauce since she likes it, along with higher calorie snacks.
CORRECT
To improve the client's nutrition, the nurse needs to consider the likes and dislikes of the client in addition to the
needed nutrients. Combining applesauce, which the client likes, but which is not a really high calorie snack, with
snacks which contain more calories, best meets the needs of the client.
D) Applesauce is an excellent source of nutrients and calories.
INCORRECT
A half-cup serving of applesauce provides 90 calories and minimal nutrients.

Mrs. Rusk has a new prescription for an appetite stimulant.

15.
Before advising Mrs. Rusk when she should take the medication, the nurse should obtain what information about
the drug?
A) Onset of action.
CORRECT
The nurse should determine when the drug will start to take effect, so that the medication can be taken when the
greatest therapeutic effect can be achieved.
B) Therapeutic index.
INCORRECT
The therapeutic index is a measure of the range of the drug's therapeutic range. A narrow therapeutic index
indicates increased risk for drug toxicity.
C) Drug half life.
INCORRECT
The drug half life provides information about the length of time the drug remains in the body.
D) Bioavailability.
INCORRECT
Bioavailability refers to the amount of drug available in the systemic circulation following the process of absorption.

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?
A) "You shouldn't worry about the cost of medications right now; you should purchase whatever your wife needs to
get well."
INCORRECT
This response is condescending and does not provide Mr. Rusk with helpful information.
B) "Brand name medications are generally more effective than generic drugs, so they are worth the additional
cost."
INCORRECT
Brand name and generic medications are bioequivalent, the active ingredients are the same.
C) "Brand name drugs and generic drugs are bioequivalent, so Mrs. Rusk can safely take either form of the
medication."
INCORRECT
Although brand name and generic medications are bioequivalent, the inert ingredients may vary, sometimes
resulting in differing effects.
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."
CORRECT
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.

Ethical-Legal Considerations
Mrs. Rusk gradually weakens and is admitted to the nearby medical center. Her health care provider recommends
the insertion of a feeding tube, by means of a percutaneous esophageal gastrostomy (PEG). Mrs. Rusk signs the
consent form and the procedure is 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 arrest,
which is confirmed in the prescriptions written by the health care provider. While conversing with Mr. and Mrs.
Rusk, Mr. Rusk confirms that Mrs. Rusk has asked that "no heroic measures be taken to save her life."

17.
What action should the nurse take?
A) Meet privately with Mr. Rusk to discuss that a feeding tube can be considered a heroic means of keeping a client
alive.
INCORRECT
Mrs. Rusk has already made a decision to undergo the procedure.
B) Inform Mrs. Rusk that the instructions in her advanced directive cannot be followed if she has a feeding tube.
INCORRECT
Resuscitative measures can be withheld from a client with 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.
INCORRECT
There is no reason to question the client's decision in this situation.
D) Advise Mrs. Rusk that an identifying bracelet needs to be secured on her wrist in case an emergency occurs.
CORRECT
An identifying wrist bracelet indicating that resuscitation should not be performed helps ensure that the client's
wishes are known and respected.

The next morning, the nurse enters Mrs. Rusk's room to prepare her to go to the procedure 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 the procedure performed, stating she would rather just "go ahead
and die." Her husband is in the room, and is very upset by his wife's comment.

18.
What action should the nurse implement?
A) Provide the couple with privacy to discuss the decision.
CORRECT
The nurse must address the client's expressed desire to cancel the procedure. The nurse's initial actions should
include allowing the couple privacy to discuss the decision, addressing any concerns of the client, and encouraging
further communication.
B) Continue to prepare the client for the scheduled procedure.
INCORRECT
The nurse must respond to the client's statement.
C) Remind the client that the consent form is already signed.
INCORRECT
The client has the right to change her mind after the consent form is signed.
D) Ask the client's husband if the procedure should be cancelled.
INCORRECT
The client's husband is not responsible for making this decision.
The couple discusses the decision together, and Mrs. Rusk decides to have the procedure as scheduled. She is
taken to the procedure room where a PEG tube is inserted.

Care of a Client with a Feeding Tube

Mrs. Rusk returns to her room following the insertion of the PEG tube. She has an IV of Lactated Ringer's Solution
infusing at 50 ml/hour, but does not have any feeding solution attached to the PEG tube.

19.
What initial action should the nurse implement?
A) Connect the Lactated Ringer's solution to the PEG tube at the prescribed rate.
INCORRECT
Intravenous fluids should not be administered through a feeding tube.
B) Prepare to infuse water slowly through the PEG tube for the first 8 hours.
INCORRECT
Tap water should not be infused at this time, but may be infused within 2 hours after placement.
C) Call the dietary department and request immediate delivery of the feeding solution.
INCORRECT
Feeding supplements are not typically initiated immediately after PEG tube insertion.
D) Continue to monitor the client without infusing any solution through the PEG tube.
CORRECT

Feeding supplements are typically initiated when bowel sounds are present, usually within 24 hours following PEG
tube insertion.

The nurse observes that the dressing around the PEG tube insertion site is intact, with a small amount of
serosanguineous drainage.

20.
What action should the nurse implement?
A) Apply a pressure dressing over the initial dressing.
INCORRECT
It is not necessary to apply a pressure dressing around a PEG tube insertion site.
B) Circle the amount of drainage on the initial dressing.
CORRECT
Circling this small amount of drainage allows the nurse to compare any changes in the amount of drainage at a
later time.
C) Remove the dressing and apply a new sterile dressing.
INCORRECT
A small amount of serosanguineous drainage does not require the removal of the initial dressing.
D) Notify the health care provider of the finding immediately.
INCORRECT
This amount of drainage is expected and notification of the health care provider is not necessary.

Formula Calculation
The next day, the nurse initiates the feeding prescribed by the 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.)
60
INCORRECT
Please recalculate.

After infusing the half strength formula at 40 ml/hour for 6 hours, the nurse checks the client's 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 than half the previously infused total volume.

22.
What action should the nurse implement?
A) Decrease the rate of the formula to 30 ml/hour.
INCORRECT
Re-calculate.
B) Maintain the rate of the formula at 40 ml/hour.
INCORRECT
Re-calculate.
C) Increase the rate of the formula to 50 ml/hour.
CORRECT
The client has received 240 ml during the previous 6 hours. Half of that volume is 120 ml. The residual volume
obtained was 75 ml, so the rate of formula should be increased by 10 ml/hour to 50 ml/hour.
D) Increase the rate of the formula to 75 ml/hour.
INCORRECT
Re-calculate.

Client Teaching
Over time, the continuous feeding is increased to 80 ml/hour and changed to full strength formula. The nurse plans
to teach Mr. Rusk how to manage the continuous feeding when Mrs. Rusk is discharged.

23.
Before beginning the teaching plan, what action is most important for the nurse to implement?
A) Ask about the couple's financial resources.
INCORRECT
Another action is more important prior to beginning client teaching.
B) Learn Mrs. Rusk's anticipated discharge date.
INCORRECT
Another action is more important prior to beginning client teaching.
C) Determine if Mr. Rusk feels ready to learn the skill.
CORRECT
Readiness to learn is essential for effective teaching. If Mr. Rusk expresses a lack of readiness to learn, the nurse
can obtain further data, such as information about financial resources, which may be impacting his readiness to
learn.
D) Obtain information about the couple's educational level.
INCORRECT
Another action is more important prior to beginning client teaching.

When the nurse demonstrates the use of the feeding equipment, Mr. Rusk looks away. The nurse observes that he
is crying.

24.
What action should the nurse implement?
A) Continue with the demonstration of the equipment while allowing Mr. Rusk time to control his emotions.
INCORRECT

This will not provide the most effective teaching.

B) Reassure Mr. Rusk that management of the feeding equipment can be easily mastered with some practice.
INCORRECT
This action is based on an assumption of the reason for Mr. Rusk's tears.
C) Stop the demonstration and leave the room until Mr. Rusk states he is ready to continue with the teaching
session.
INCORRECT
Another action is more helpful to Mr. Rusk.
D) Acknowledge the stressful nature of the situation and ask Mr. Rusk if he feels ready to continue.
CORRECT
This is a therapeutic response, offering support and allowing Mr. Rusk to feel in control of the situation.

Bolus Feedings
The feedings are changed to bolus feeding 3 times a day. After receiving instruction, Mr. Rusk demonstrates correct
ability to perform the skill and states he feels he can handle this responsibility. Mrs. Rusk is discharged home and
home health care services resume. During a home visit, the nurse observes Mr. Rusk as he administers a bolus
feeding to Mrs. 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 tube. He then holds the syringe upright while the feeding enters
the stomach.

25.
In observing this procedure, what action should the nurse take?
A) Teach Mr. Rusk to lower the syringe to increase the speed of the feeding.
INCORRECT
Lowering the syringe will decrease the speed of the gravity feeding.
B) Lower the head of the bed until the feeding has all drained from the syringe.
INCORRECT
Lowering the head of the bed increases the risk for aspiration.
C) Remind Mr. Rusk to check for residual again after the feeding has entered the stomach.
INCORRECT
Residual feeding is checked prior to beginning the feeding. Checking for residual immediately after the feeding will
result in removal of the feeding just administered.
D) Ensure that Mr. Rusk flushes the tubing with water after the syringe is empty of feeding.
CORRECT
Flushing the syringe and tubing with water reduces the risk for obstruction of the tubing.

While Mr. Rusk administers the feeding, Mrs. Rusk tells the nurse that she has had 5 to 7 liquid diarrhea stools a
day for the last 2 days.

26.
What action should the nurse implement first?
A) Notify the health care provider of the diarrhea.

INCORRECT
This action may be necessary, but is not the best initial action by the nurse.
B) Tell Mr. Rusk to hold the remaining feeding.
CORRECT
Tube feedings may cause diarrhea. The nurse should first advise Mr. Rusk to hold the remaining feeding until
further assessment is completed.
C) Assess the elasticity of Mrs. Rusk's skin.
INCORRECT
Frequent diarrhea can impact fluid volume status, so the nurse should assess the elasticity of the client's skin.
However, another action should be implemented first.
D) Auscultate for the presence of bowel sounds.
INCORRECT
This is an important assessment for the client with altered bowel patterns, but another action should be
implemented first.

Case Outcome
A change in the amount and frequency of the feedings eliminates Mrs. Rusk's diarrhea. After continued work with
the speech therapist, Mrs. Rusk is able to swallow more effectively and no longer requires the PEG tube feedings.
She continues to live at home, cared for by her husband, with support from the home health care team.