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A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?
- A. Administer an antiemetic.
- B. Check the client's gastric residual.
- C. Hold the client's feeding.
- D. Reduce the rate of the tube feeding by half.
Correct Answer: C
Rationale: The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate without a provider's order. Checking gastric residual is important but not while the client is vomiting. Continuing to feed the client during vomiting is unsafe.
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A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this client's height?
- A. Add the trunk and leg measurements.
- B. Ask the client how tall he or she is.
- C. Estimate by measuring clothing.
- D. Use knee-height calipers.
Correct Answer: D
Rationale: A sliding blade knee-height caliper is used to obtain the height of a client who cannot stand upright, such as those with kyphosis or lower extremity contractures. The other methods will not yield accurate data.
A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, what should the nurse assess as the priority?
- A. Economic ability to join a gym.
- B. Food allergies and intolerances.
- C. Psychosocial influences on weight.
- D. Reasons for wanting to lose weight.
Correct Answer: C
Rationale: Psychosocial influences, such as stress, emotional eating, or social pressures, can significantly impact weight management and should be assessed as a priority to provide holistic care. Economic ability, food allergies, and reasons for weight loss are important but secondary.
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client's pulse is 128 beats/min, blood pressure is 90/56 mm Hg, and skin turgor is dry. What action should the nurse perform next?
- A. Calculate the client's 24-hour intake, output, and fluid balance.
- B. Assess the client's oral cavity.
- C. Prepare to hang a normal saline bolus.
- D. Notify the provider immediately.
Correct Answer: A
Rationale: The client has clinical indicators of dehydration, so the nurse calculates the client's 24-hour intake, output, and fluid balance. This information is then reported to the provider. Assessing the oral cavity may or may not be consistent with dehydration. A fluid bolus may be needed, but not as an independent action. Notifying the provider is appropriate after data collection.
A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first?
- A. Client with a blood glucose level of 138 mg/dL.
- B. Client with foul-smelling diarrhea.
- C. Client with a potassium level of 2.6 mEq/L.
- D. Client with a sodium level of 138 mEq/L.
Correct Answer: C
Rationale: The potassium level of 2.6 mEq/L is critically low, possibly due to hyperglycemia-induced hyperosmolality. The nurse should see this client first. The blood glucose reading is high but not extreme. The sodium level is normal. The client with diarrhea should be seen last to avoid cross-contamination.
A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important?
- A. Assessing blood glucose as directed.
- B. Changing the IV dressing each day.
- C. Checking the IV site for redness.
- D. Performing appropriate hand hygiene.
Correct Answer: D
Rationale: Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose and the IV site are important, but preventing infection takes priority.