Nokea
A client is receiving continuous tube feeding at 70 mL/hr. When the bag is empty, how much formula does the nurse add? (Record your answer using a whole number.) mL
- A. 280
- B. 350
- C. 210
- D. 420
Correct Answer: A
Rationale: The nurse never adds more than 4 hours' worth of formula to a hanging bag of enteral feedings: 70 mL/hr ? 4 hr = 280 mL.
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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.
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 and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition?
- A. Client with congestive heart failure
- B. Client with renal failure
- C. Client who has malnutrition
- D. Client who is post gastric resection
Correct Answer: A
Rationale: Clients receiving PPN typically get large amounts of fluid volume, making the client with congestive heart failure a poor candidate due to the risk of fluid overload. The other candidates are appropriate for this type of nutritional support.
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 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.