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A client is receiving bolus feedings through a Dobbloff tube. What action by the nurse is most important?
- A. Auscultate lung sounds after each feeding.
- B. Check tube placement before each feeding.
- C. Check tube placement every 8 hours.
- D. Weigh the client daily on the same scale.
Correct Answer: B
Rationale: For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will not prevent misplacement issues. Weighing the client is important to determine if nutritional goals are being met.
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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.
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 is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says,'I didn't know it would be this hard to live like this.' What response by the nurse is best?
- A. Assess the client's coping and support systems.
- B. Inform the client that things will get easier.
- C. Re-educate the client on needed dietary changes.
- D. Tell the client lifestyle changes are always hard.
Correct Answer: A
Rationale: The nurse should assess this client's coping styles and support systems to provide holistic care. The other options do not adequately address the client's emotional distress.
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.
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.