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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.
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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 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.
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 nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate?
- A. Ask another nurse to help next time.
- B. Request bariatric equipment for the client.
- C. Fill out and file a variance report.
- D. Refuse to care for the client again.
Correct Answer: C
Rationale: The nurse should complete a variance report per agency policy to document the injury. Asking for help and requesting equipment are good ideas, but the injury needs to be reported. Refusing care is unethical.
A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.)
- A. Attempt to dislodge the clog by instilling a cola product.
- B. Determine if any of the medications come in a liquid form.
- C. Flush the tube before and after administering medications.
- D. Administer medications with a feeding pump.
- E. Try to flush the tube with 30 mL of water and gentle pressure.
Correct Answer: B,C,E
Rationale: If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube with water. Cola products should not be used unless water is ineffective. To prevent future problems, determine if medications can be dispensed in liquid form and flush the tube with water before and after medication administration.