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A client is in the family practice clinic. Today the client weighs 180.4 pounds (84.7 kg). Six months ago, the client weighed 201.8 pounds (96.2 kg). What action by the nurse is best?
- A. Ask the client if the weight loss was intentional.
- B. Determine if there are food allergies or intolerances.
- C. Determine if there are food allergies or intolerance.
- D. Perform a rapid bedside blood glucose test.
Correct Answer: A
Rationale: This client has had 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on the risk factors, a blood glucose test may be warranted.
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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 weighs 225 pounds (102.1 kg) and is 5'3"? (160.0 cm) tall. What is this client's body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.)
- A. 40.4
- B. 35.2
- C. 45.8
- D. 38.6
Correct Answer: A
Rationale: Using the formula BMI = weight (kg) / [height (m)]^2: 102.1 / (1.6)^2 = 40.4, rounded to the nearest tenth.
A client just returned to the surgical unit after bariatric surgery. What is the priority action by the nurse?
- A. Assess the client's pain.
- B. Check the surgical incision.
- C. Ensure a patent airway.
- D. Program the morphine pump.
Correct Answer: C
Rationale: Airway is always the priority, especially in bariatric clients who may have short, thick necks that complicate airway management. The other actions are appropriate but secondary to ensuring a patent airway.
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.
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.