During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

Medications need to be documented in the record for the physician's review.

The nurse needs to assess the patient for allergic reactions.

Certain drugs can affect the metabolism of nutrients.

Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While documenting medications is important for the physician's review, this is not the primary nutritional assessment reason for asking about medications. The focus here is on how medications interact with nutritional status.

Choice B rationale

Assessing for allergic reactions to medications is crucial for patient safety, but it is a separate aspect of medication history and not directly related to the metabolism of nutrients during a nutritional assessment.

Choice C rationale

Certain medications can significantly interfere with the absorption, metabolism, and excretion of various nutrients. For example, some drugs can increase nutrient excretion, decrease appetite, or alter the body's ability to utilize vitamins and minerals, directly impacting nutritional status.

Choice D rationale

While some medications can affect memory and thus the accuracy of a 24-hour food recall, the more direct and critical reason for asking about medications during a nutritional assessment is to identify potential drug-nutrient interactions that affect metabolism.

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Correct Answer is A,B,C,D

Explanation

Choice A rationale

Verifying tube placement is the initial critical step to ensure the feeding is delivered into the gastrointestinal tract and not the respiratory system, thereby preventing aspiration. Methods for verification include pH testing of aspirate (target pH ≤ 5.5), and radiographic confirmation is the gold standard, especially after initial placement.

Choice B rationale

Checking the residual feeding contents before administering a new feeding is essential to assess the client's tolerance to the previous feeding and prevent overfeeding, which can lead to complications like abdominal distension, nausea, vomiting, and aspiration. A high residual volume may indicate delayed gastric emptying.

Choice C rationale

Administering the feeding follows confirmation of tube placement and assessment of residual volume. The feeding should be administered at the prescribed rate and volume, ensuring the client receives adequate nutrition and hydration. The client should be positioned with the head of the bed elevated at least 30-45 degrees during and for at least 30-60 minutes after feeding to minimize aspiration risk.

Choice D rationale

Evaluating the client's tolerance to the feeding is an ongoing process that involves monitoring for signs and symptoms such as abdominal distension, pain, nausea, vomiting, diarrhea, or aspiration. This evaluation helps determine if the feeding regimen needs adjustment in terms of rate, volume, or formula.

A. Hypoglycemia. B. Hyperthermia. C. Flatulence. D. Tachycardia.

Correct Answer is A

Explanation

Choice A rationale

Abrupt cessation of total parenteral nutrition (TPN) can lead to a rapid decrease in blood glucose levels. While receiving TPN, the body is continuously supplied with glucose. When this external glucose source is suddenly removed, the pancreas may continue to secrete insulin at a rate higher than needed, resulting in hypoglycemia. Signs and symptoms of hypoglycemia include sweating, tremors, confusion, and dizziness.

Choice B rationale

Hyperthermia, or elevated body temperature above the normal range of approximately 36.5°C to 37.5°C (97.7°F to 99.5°F), is not a typical complication following the discontinuation of TPN. Fever is usually associated with infection or inflammation, neither of which are a direct consequence of stopping TPN.

Choice C rationale

Flatulence, or the accumulation of gas in the digestive tract leading to bloating and the passage of gas, is related to dietary intake and digestive processes. Discontinuing TPN, which bypasses the digestive system, would not directly cause an increase in flatulence. In fact, digestive issues might improve once oral or enteral feeding resumes.

Choice D rationale

Tachycardia, an abnormally rapid heart rate (typically defined as above 100 beats per minute in adults), is not a direct physiological consequence of discontinuing TPN. While changes in fluid balance or electrolyte levels (which can occur with TPN but are monitored closely) could indirectly affect heart rate, hypoglycemia is a more immediate and direct risk upon TPN cessation.

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During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

What should the nurse assess the patient for after discontinuing the TPN?

Correct Answer is A

Explanation

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