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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.
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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.
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 is weighing and measuring a client with severe kyphosis. What is the best method to obtain this client's height?
- A. Add the trunk and leg measurements.
- B. Ask the client how tall he or she is.
- C. Estimate by measuring clothing.
- D. Use knee-height calipers.
Correct Answer: D
Rationale: A sliding blade knee-height caliper is used to obtain the height of a client who cannot stand upright, such as those with kyphosis or lower extremity contractures. The other methods will not yield accurate data.
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.