Altered Nutrition - HESI Case Study
After establishing priorities, the nurse should take which action next in developing Mrs. Rusk's
plan of care? - ANS-Establish goals.
After infusing the half-strength formula at 30 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.
What action should the nurse implement? - ANS-Increase the rate of the formula to 40 mL/hour.
Before notifying the healthcare provider of the data reported by the nutritionist, what information
is most important for the nurse to obtain? - ANS-Client's calculated body mass index.
During a home visit a week later, the nurse assesses Mrs. Rusk's nutritional status.
Which data indicates the need for the nurse to evaluate Mrs. Rusk further for altered nutrition?
(Select all that apply.) - ANS-The conjunctival sac is pale in appearance when exposed.
The skin over the sternum tents when pinched.
The lips are dry and cracked.
In developing the plan of care, the nurse recognizes that Mrs. Rusk's dysphagia may impact her
fluid and nutritional status.
The nurse plans interventions related to Mrs. Rusk's dysphagia. To which member of the
interprofessional team should the nurse refer Mrs. Rusk? - ANS-Speech therapist.
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."
How should the nurse respond? - ANS-"Your pharmacist and healthcare provider can determine
if there is a generic drug that is a safe alternative to the brand name drug."
Mrs. Rusk gradually weakens and is admitted to the nearby medical center. Her HCP
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 advance
directive requesting that she not be resuscitated in the event of an arrest, which is confirmed in
the prescriptions written by the HCP. While the nurse is conversing with Mr. and Mrs. Rusk, Mr.
Rusk confirms that Mrs. Rusk has asked that "no heroic measures be taken to save her life."
What action should the nurse take? - ANS-Advise Mrs. Rusk that an identifying bracelet needs
to be secured on her wrist in case an emergency occurs.
Mrs. Rusk has a new prescription for an appetite stimulant.
After establishing priorities, the nurse should take which action next in developing Mrs. Rusk's
plan of care? - ANS-Establish goals.
After infusing the half-strength formula at 30 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.
What action should the nurse implement? - ANS-Increase the rate of the formula to 40 mL/hour.
Before notifying the healthcare provider of the data reported by the nutritionist, what information
is most important for the nurse to obtain? - ANS-Client's calculated body mass index.
During a home visit a week later, the nurse assesses Mrs. Rusk's nutritional status.
Which data indicates the need for the nurse to evaluate Mrs. Rusk further for altered nutrition?
(Select all that apply.) - ANS-The conjunctival sac is pale in appearance when exposed.
The skin over the sternum tents when pinched.
The lips are dry and cracked.
In developing the plan of care, the nurse recognizes that Mrs. Rusk's dysphagia may impact her
fluid and nutritional status.
The nurse plans interventions related to Mrs. Rusk's dysphagia. To which member of the
interprofessional team should the nurse refer Mrs. Rusk? - ANS-Speech therapist.
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."
How should the nurse respond? - ANS-"Your pharmacist and healthcare provider can determine
if there is a generic drug that is a safe alternative to the brand name drug."
Mrs. Rusk gradually weakens and is admitted to the nearby medical center. Her HCP
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 advance
directive requesting that she not be resuscitated in the event of an arrest, which is confirmed in
the prescriptions written by the HCP. While the nurse is conversing with Mr. and Mrs. Rusk, Mr.
Rusk confirms that Mrs. Rusk has asked that "no heroic measures be taken to save her life."
What action should the nurse take? - ANS-Advise Mrs. Rusk that an identifying bracelet needs
to be secured on her wrist in case an emergency occurs.
Mrs. Rusk has a new prescription for an appetite stimulant.
