The nurse is assessing an older female adult's client's nutritional status. Which finding indicates that the client has a nutritional deficiency?

Reference Ranges:

Hemoglobin [12 to 16 g/dl (120 to 160 g/L)]

Hematocrit 37% to 47% (0.37 to 0.47 volume fraction)]

Albumin [3.5 to 5.0 g/dl (35 to 50 g/L)]

Serum transferrin [250 to 380 mg/dl (2.5 to 3.80 g/L)]

A hemoglobin (Hgb) of 11.8 g/dL (118 g/L) and hematocrit (Hct) of 34% (0.34).

Low weight as determined from a height/weight comparison chart.

Decreased lean body mass compared to results of 10 years ago.

Serum albumin of 3 g/dL (30 g/L) and serum transferrin of 180 mg/dL (1.8 g/L).

Answer and Explanation

The Correct Answer is D

A.   Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B.   Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C.   A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D.   Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

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Correct Answer is C

Explanation

A. Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B. Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C. Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D. Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

A. Place client on her left side while delivering the bolus. B. Ask the client to select a preferred flavor for the bolus. C. Elevate head of bed 30 degrees for 1 hour after bolus. D. Flush tubing with warm water before and after bolus. E. Include amount of feeding when recording fluid Intake.

Correct Answer is ["C","D","E"]

Explanation

A. Placing the client on her left side is not a standard practice for delivering enteral feedings. Generally, the client should be in a semi-Fowler’s position (head of bed elevated at 30-45 degrees) to minimize the risk of aspiration and aid in digestion.
B. While asking for a preferred flavor may be appropriate for improving patient comfort and adherence to the feeding regimen, it is not always feasible or necessary, particularly if the client has limited ability to communicate or make choices.
C. Elevating the head of the bed to 30 degrees for 1 hour after administering a bolus feeding helps to reduce the risk of aspiration and aids in digestion by allowing gravity to assist in moving the feeding into the stomach. This is a standard practice for patients receiving enteral feedings and is important for preventing complications like aspiration pneumonia.
D. Flushing the tubing with warm water before and after administering the bolus is essential to ensure that the entire amount of feeding is delivered and to prevent clogging of the tube. This practice helps in maintaining tube patency and ensuring that the client receives the full intended dose of nutrition.
E. It is important to record the amount of enteral feeding as part of the client’s total fluid intake. Accurate documentation helps in monitoring the client’s fluid balance and nutritional intake, which is critical for managing the client’s overall health and adjusting their care plan as needed.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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