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A client is awaiting bariatric surgery in the morning. What action by the nurse is most important?
- A. Answering questions about the surgery.
- B. Beginning venous thromboembolism prophylaxis.
- C. Informing the client that he or she will be out of bed tomorrow.
- D. Teaching the client about needed dietary changes.
Correct Answer: B
Rationale: Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this as a priority. Answering questions is the surgeon's role, and teaching is important but secondary to safety.
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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 nursing student is studying nutritional problems and learns that kwashiorer is distinguished from measures and which finding?
- A. Deficit of calories
- B. Lack of nutrients
- C. Specific lack of protein
- D. Unknown cause of malnutrition
Correct Answer: C
Rationale: Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition.
A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate?
- A. Assess the client's readiness to make lifestyle changes.
- B. Leave siderails down to prevent pressure ulcers.
- C. Refer the client to a bariatric center.
- D. Ensure appropriate bariatric equipment is available.
Correct Answer: D
Rationale: Many hospitals that see bariatric-sized clients have appropriate equipment for this population. Ensuring the availability of proper equipment is critical for patient and staff safety. The other options are relevant but not the priority.
Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because'I just have to know how much she weighs.' What action by the client's nurse is most appropriate?
- A. Make an anonymous report to the charge nurse.
- B. State,'That is a violation of client confidentiality.'
- C. Walk away and ignore the other nurse's behavior.
- D. Document the incident in the client's chart.
Correct Answer: B
Rationale: Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.
A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessment is a priority?
- A. Albumin: 5.5 g/Dl
- B. Cholesterol: 142 mg/dL
- C. Protein: 6.5 g\dL
- D. Hemoglobin: 9.8 g/dL
Correct Answer: B
Rationale: A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and protein levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.