A nurse is caring for a client who has a pressure injury and is assessing the client's dietary intake. Which of the following factors should the nurse identify as a barrier to wound healing?

Decreased fat intake

Decreased vitamin C intake

Increased protein intake

Increased caloric intake

Answer and Explanation

The Correct Answer is B

Choice A reason: Decreased fat intake is not a barrier to wound healing, as long as the client meets the recommended daily intake of essential fatty acids. Fat is important for cell membrane integrity, inflammation, and immune function. However, excessive fat intake can increase the risk of obesity, diabetes, and cardiovascular disease, which can impair wound healing.

Choice B reason: Decreased vitamin C intake is a barrier to wound healing, as vitamin C is essential for collagen synthesis, wound repair, and antioxidant activity. Vitamin C deficiency can lead to impaired wound healing, increased susceptibility to infection, and scurvy. The nurse should encourage the client to consume foods rich in vitamin C, such as citrus fruits, berries, peppers, broccoli, and tomatoes.

Choice C reason: Increased protein intake is not a barrier to wound healing, but rather a facilitator of wound healing, as protein is necessary for tissue growth, repair, and maintenance. Protein deficiency can result in delayed wound healing, increased risk of infection, and loss of lean body mass. The nurse should advise the client to consume adequate amounts of high-quality protein, such as eggs, milk, cheese, meat, fish, poultry, soy, and nuts.

Choice D reason: Increased caloric intake is not a barrier to wound healing, but rather a facilitator of wound healing, as calories provide energy for wound healing processes. Caloric deficiency can lead to malnutrition, weight loss, and impaired wound healing. The nurse should ensure that the client meets their caloric needs based on their age, weight, activity level, and wound severity.

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Correct Answer is A

Explanation

Choice A reason: Warming the formula to room temperature can help reduce the osmotic load and prevent diarrhea in clients receiving enteral nutrition. Cold formula can also cause abdominal cramping and discomfort.

Choice B reason: Increasing the rate of infusion can worsen diarrhea by increasing the osmotic load and the risk of bacterial overgrowth. The rate of infusion should be adjusted based on the client's tolerance and nutritional needs.

Choice C reason: Changing to a low-calorie formula is not indicated for diarrhea. Low-calorie formulas are usually high in osmolality and can cause more water to be drawn into the intestinal lumen, leading to diarrhea. A low-residue or isotonic formula may be more appropriate.

Choice D reason: Replacing the extension tubing every 48 hr is not enough to prevent diarrhea. The extension tubing should be replaced every 24 hr or with each new container of formula to reduce the risk of bacterial contamination and infection.

A. Wear sterile gloves during a feeding. B. Chill the feeding prior to administering. C. Flush the tubing with 15 mL of water after each feeding. D. Position the client upright prior to a feeding.

Correct Answer is C

Explanation

Choice C reason: Flushing the tubing with water after each feeding is important to prevent clogging, maintain patency, and clear any residual formula from the tube. It also helps to prevent bacterial growth and infection.

Choice A reason: Wearing sterile gloves during a feeding is not necessary, as enteral feedings are not considered sterile procedures. Clean gloves are sufficient to prevent contamination and protect the nurse and the client.

Choice B reason: Chilling the feeding prior to administering is not recommended, as cold formula can cause abdominal cramping, discomfort, and diarrhea. The formula should be at room temperature or slightly warmed before giving it to the client.

Choice D reason: Positioning the client upright prior to a feeding is correct, but it is not enough. The client should remain upright for at least 30 minutes after the feeding as well, to prevent aspiration, reflux, and nausea.

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A nurse is caring for a client who has a pressure injury and is assessing the client's dietary intake. Which of the following factors should the nurse identify as a barrier to wound healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving continuous enteral nutrition and is experiencing diarrhea. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching the partner of a client about administering intermittent enteral feedings. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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