Nokea
A client is discussing weight loss medications with the nurse. Which statement by the nurse is most appropriate?
- A. Only over-the-counter medications are available.
- B. There are three drugs currently approved for this.
- C. The patient operation is available in a reduced-dose over-the-counter formulation.
- D. Prescription medications are not effective for weight loss.
Correct Answer: B
Rationale: There are three drugs available by prescription for weight loss, including orlistat (Xenical). The other statements are incorrect as over-the-counter options are limited, and prescription medications can be effective.
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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.
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 nurse is caring for a client receiving enteral feeding through a Dobhoff tube. What action by the nurse is best to prevent hypernatremia?
- A. Administer free-water boluses as prescribed.
- B. Change the client's formula.
- C. Dilute the client's formula.
- D. Slow the rate of the infusion.
Correct Answer: A
Rationale: Protein and sugar molecules in the enteral feeding product contribute to dehydration due to increased osmolality. The nurse can administer free-water boluses after consulting with the provider on the appropriate amount and timing, or per protocol. Changing or diluting the formula is not appropriate. Slowing the infusion rate will not address the problem.
When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.)
- A. Allow uninterrupted time for eating.
- B. Assess dentures for appropriate fit.
- C. Ensure the client wears glasses if needed.
- D. Provide daily foods that the client can taste.
- E. Serve high-calorie, high-protein snacks.
Correct Answer: A,B,C,E
Rationale: Older adults need unhurried and uninterrupted time for eating. Dentures and glasses, if needed, should fit appropriately. High-calorie, high-protein snacks are beneficial. Salty snacks are not recommended due to sodium restrictions.
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.