Chapter 55: Concepts of Care for Patients
with Malnutrition: Undernutrition and
Obesity
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is managing care for a client receiving feeding through a gastrostomy tube
(G-tube). What assessment would the nurse perform?
a. Check the skin around the tube insertion site.
b. Weigh the client every shift with the same scale.
c. Draw blood to assess albumin every shift.
d. Irrigate the tube at least once a day.
ANS: A
The most important assessment would be to observe the skin around the tube for
irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep
it free of drainage and moisture which can lead to excoriation or other type of skin
breakdown. For a client who is undernourished, he or she is usually weighed every
day and prealbumin is a more sensitive indicator of over nutritional health. The G-
tube is not routinely irrigated.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Undernutrition, Total enteral nutrition MSC: Client
Needs Category: Physiological Integrity: Physiological Adaptation
, 2. A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes
that the client’s pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry,
and skin turgor is poor. What action should the nurse perform next?
a. Assess the 24-hour intake and output.
b. Assess the client’s oral cavity.
c. Prepare to hang a normal saline bolus.
d. Increase the infusion rate of the TPN.
ANS: A
This client has clinical indicators of dehydration, so the nurse calculates the patient’s
24-hour intake, output, and fluid balance. This information is then reported to the
health care provider. The client’s oral cavity assessment may or may not be consistent
with dehydration. The nurse may need to give the client a fluid bolus, but not as an
independent action. The client’s dehydration is most likely due to fluid shifts from the
TPN, so increasing the infusion rate would make the problem worse, and is not done
as an independent action for clients receiving TPN.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Undernutrition, Parenteral nutrition MSC: Client Needs
Category: Physiological Integrity: Physiological Adaptation
3. A client who had minimally invasive bypass gastric surgery 2 days ago reports new-
onset of severe abdominal pain. What is the nurse’s best action as this time?
a. Listen to the client’s bowel sounds.
b. Call the Rapid Response Team.
c. Take the client’s vital signs.
d. Contact the primary health care provider.
ANS: C
The client may be experiencing either bleeding or anastomosis leak(s). Clients having
these complications have severe abdominal, back, or shoulder pain, tachycardia, and
hypotension.
with Malnutrition: Undernutrition and
Obesity
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is managing care for a client receiving feeding through a gastrostomy tube
(G-tube). What assessment would the nurse perform?
a. Check the skin around the tube insertion site.
b. Weigh the client every shift with the same scale.
c. Draw blood to assess albumin every shift.
d. Irrigate the tube at least once a day.
ANS: A
The most important assessment would be to observe the skin around the tube for
irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep
it free of drainage and moisture which can lead to excoriation or other type of skin
breakdown. For a client who is undernourished, he or she is usually weighed every
day and prealbumin is a more sensitive indicator of over nutritional health. The G-
tube is not routinely irrigated.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Undernutrition, Total enteral nutrition MSC: Client
Needs Category: Physiological Integrity: Physiological Adaptation
, 2. A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes
that the client’s pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry,
and skin turgor is poor. What action should the nurse perform next?
a. Assess the 24-hour intake and output.
b. Assess the client’s oral cavity.
c. Prepare to hang a normal saline bolus.
d. Increase the infusion rate of the TPN.
ANS: A
This client has clinical indicators of dehydration, so the nurse calculates the patient’s
24-hour intake, output, and fluid balance. This information is then reported to the
health care provider. The client’s oral cavity assessment may or may not be consistent
with dehydration. The nurse may need to give the client a fluid bolus, but not as an
independent action. The client’s dehydration is most likely due to fluid shifts from the
TPN, so increasing the infusion rate would make the problem worse, and is not done
as an independent action for clients receiving TPN.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Undernutrition, Parenteral nutrition MSC: Client Needs
Category: Physiological Integrity: Physiological Adaptation
3. A client who had minimally invasive bypass gastric surgery 2 days ago reports new-
onset of severe abdominal pain. What is the nurse’s best action as this time?
a. Listen to the client’s bowel sounds.
b. Call the Rapid Response Team.
c. Take the client’s vital signs.
d. Contact the primary health care provider.
ANS: C
The client may be experiencing either bleeding or anastomosis leak(s). Clients having
these complications have severe abdominal, back, or shoulder pain, tachycardia, and
hypotension.
