A nurse is providing care for a patient who is due for surgery.
The patient’s lab results and physical history are as follows: Prealbumin level is 13 mg/dL (normal range: 15 to 36 mg/dL), Cholesterol is 230 mg/dL (normal is less than 200 mg/dL), and Fasting glucose is 110 mg/dL (normal range: 70 to 110 mg/dL). The patient has a history of hyperlipidemia and diabetes mellitus.
Which of the following factors could potentially delay the patient’s wound healing process?

The patient’s medication history

The patient’s cholesterol level

The patient’s prealbumin level

The patient’s fasting glucose level

Answer and Explanation

The Correct Answer is C

Choice A rationale

While a patient’s medication history can impact wound healing, in this case, there is no specific information provided about the patient’s medications that would suggest a delay in wound healing.

Choice B rationale

Although the patient’s cholesterol level is elevated, hyperlipidemia is not typically associated with delayed wound healing.

Choice C rationale

Prealbumin is a marker of nutritional status. A low prealbumin level, like in this patient, could indicate malnutrition, which can delay wound healing. Adequate nutrition is essential for wound healing as it provides the necessary building blocks for tissue repair.

Choice D rationale

The patient’s fasting glucose level is within the normal range, so it is unlikely to impact wound healing. While poorly controlled diabetes can delay wound healing, this patient’s diabetes appears to be well-controlled.

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Correct Answer is C

Explanation

Choice A rationale

Discarding any residual gastric contents before administering the tube feeding is not necessary and could lead to unnecessary loss of nutrients and electrolytes.

Choice B rationale

Positioning the patient in a low Fowler’s position is not the optimal position for administering a tube feeding. The patient should be in an upright position to reduce the risk of aspiration.

Choice C rationale

Testing the pH of the gastric aspirate is an important step before administering a tube feeding. This helps to verify that the feeding tube is in the stomach and not in the lungs.

Choice D rationale

Warming the feeding solution to body temperature is not necessary and could potentially lead to bacterial growth in the feeding solution.

A. Mix the three medications together prior to administering. B. Maintain the head of the bed in a flat position for 30 min following medication administration. C. Flush the NG feeding tube with 30 mL of water immediately following medication administration. D. Dilute each medication with 10 mL of tap water.

Correct Answer is C

Explanation

Rationale:

When administering multiple liquid medications through an NG tube, it’s important to administer each medication separately to prevent drug interactions. After each medication, the NG tube should be flushed with 30 mL of water to ensure that the medication has been fully administered and to prevent the tube from becoming clogged.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient in a long-term care facility who is receiving enteral feedings via a nasogastric (NG) tube.What action should the nurse take before administering the tube feeding?

Correct Answer is C

Explanation

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take?

A nurse is assessing a client who has a colostomy and notices that the stoma is pale in color. Which of the following findings should the nurse report to the provider?

A nurse is assessing a client who has impaired mobility.The nurse should monitor the client for a pressure injury due to which of the following factors?

A nurse is preparing to instill 840 mL of enteral nutrition via a patient’s gastrostomy tube over 24 hours using an infusion pump. How many mL/hr should the nurse set the infusion pump to deliver?

The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?

A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?

A nurse is educating a patient who recently had a colostomy. What information should the nurse include in the teaching?