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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.
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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 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 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.
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.