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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.
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A client wants to lose 1.5 pounds a week. After reviewing a diet history, the nurse determines the client typically eats 2450 calories a day. What should the client's calorie goal be to achieve this weight loss? (Record your answer using a whole number.) calories/day
- A. 1700
- B. 2000
- C. 1850
- D. 2200
Correct Answer: A
Rationale: To lose 1 pound a week, subtract 500 calories per day; for 2 pounds, subtract 1000 calories. For 1.5 pounds, subtract 750 calories: 2450 - 750 = 1700 calories/day.
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 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 nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessment is a priority?
- A. Albumin: 5.5 g/Dl
- B. Cholesterol: 142 mg/dL
- C. Protein: 6.5 g\dL
- D. Hemoglobin: 9.8 g/dL
Correct Answer: B
Rationale: A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and protein levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.
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.