A nurse and a dietitian are completing a nutrition assessment for a 25-year-old client. Which nutritional screening tool is used to determine if the client is mildly-to-moderately malnourished and predict outcomes for critically-ill clients?

Subjective Global Assessment (SGA).

Nutritional Risk Screening (NRS-2002).

Mini Nutritional Assessment (MNA).

Malnutrition Screening Tool (MST).

Answer and Explanation

The Correct Answer is B

Nutritional screening is a systematic process used to identify individuals at risk of protein-energy malnutrition and those who may benefit from specialized metabolic support. These tools evaluate physiological variables such as unintentional weight loss, recent dietary intake reductions, and the metabolic stress induced by the client's current pathology. For high-acuity patients, effective screening facilitates early nutritional intervention, which is statistically linked to reduced hospital stay durations and improved wound healing.

Rationale:

A. The Subjective Global Assessment is a comprehensive clinical tool used to assess nutritional status based on patient history and physical examination findings. While highly effective for identifying severe malnutrition, it is a more labor-intensive assessment rather than a rapid screening tool for predictive outcomes. It does not utilize the specific scoring system found in the NRS-2002 protocol.

B. The Nutritional Risk Screening 2002 is the gold standard for identifying mildly-to-moderately malnourished clients in the acute care setting. It incorporates a nutritional score and a severity-of-illness score, making it uniquely capable of predicting clinical outcomes for critically-ill patients. This tool is specifically designed to determine which hospitalized patients require a formal nutrition plan.

C. The Mini Nutritional Assessment is a specialized screening tool validated almost exclusively for the geriatric population aged 65 and older. It focuses on age-related factors like mobility, neuropsychological problems, and polypharmacy, which are not applicable to a 25-year-old client. It is not the primary instrument used for predicting outcomes in younger critically-ill populations.

D. The Malnutrition Screening Tool is a simplified, two-question instrument often used in outpatient or general hospital wards to identify risk quickly. While efficient, it lacks the scientific depth to categorize malnutrition severity or provide predictive data for intensive care scenarios. It is generally used for initial identification rather than detailed outcome prediction in critical illness.

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Correct Answer is B

Explanation

Brief introduction:

Purulent drainage signifies a pyogenic infection characterized by leukocyte infiltration and necrotic debris. Clinical manifestations include localized erythema, warmth, and edema, often progressing to systemic febrile responses if the causative pathogen proliferates within the subcutaneous tissue layers.

Rationale:

A. Monitoring the total leukocyte count identifies systemic inflammatory responses but does not pinpoint the specific microbial etiology. While leukocytosis indicates an active immune response, it is a nonspecific finding that does not facilitate the targeted antibiotic therapy required to resolve a localized postoperative infection.

B. Obtaining a culture and sensitivity is the definitive nursing action to identify the specific infectious agent present. This diagnostic procedure ensures the clinician can initiate pathogen-specific antimicrobial treatment, which is essential for preventing sepsis and promoting secondary intention healing in contaminated surgical sites.

C. Irrigating a surgical site with isotonic solutions removes surface debris but does not address the underlying bacterial colonization. Although debridement is a component of wound care, performing this before obtaining a specimen may contaminate the results or reduce the bacterial load needed for accurate laboratory identification.

D. Assessing for malodorous discharge provides clinical data regarding possible anaerobic involvement but remains a subjective observation. While odor can suggest specific bacteria like Pseudomonas or Proteus, it is diagnosticly inferior to laboratory culture results which provide definitive evidence for the required clinical intervention.

Correct Answer is ["31"]

Explanation

Brief introduction:

Vancomycin is a potent antibiotic used to treat serious bacterial infections, including MRSA. One of the most critical nursing responsibilities during its administration is regulating the infusion rate. Vancomycin must be infused slowly (typically no faster than 10 mg/min or over at least 60–120 minutes for higher doses) to prevent Red Man Syndrome, a hypersensitivity reaction characterized by flushing, rash, and hypotension caused by rapid histamine release.

Rationale:
Step 1: Identify the formula
gtt/min = (Total volume × Drop factor) ÷ Time (in minutes)

Step 2: Insert values
Total volume = 250 mL, Drop factor = 15 gtt/mL, Time = 2 hr × 60 = 120 min
gtt/min = (250 × 15) ÷ 120

Step 3: Calculate
= 3750 ÷ 120
≈ 31.25

Step 4: Round to the nearest whole number
≈ 31 gtt/min

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A nurse and a dietitian are completing a nutrition assessment for a 25-year-old client. Which nutritional screening tool is used to determine if the client is mildly-to-moderately malnourished and predict outcomes for critically-ill clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?

Correct Answer is B

Explanation

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 mL to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["31"]

Explanation

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