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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.
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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.
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.
A client weighs 225 pounds (102.1 kg) and is 5'3"? (160.0 cm) tall. What is this client's body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.)
- A. 40.4
- B. 35.2
- C. 45.8
- D. 38.6
Correct Answer: A
Rationale: Using the formula BMI = weight (kg) / [height (m)]^2: 102.1 / (1.6)^2 = 40.4, rounded to the nearest tenth.
A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?
- A. Administer an antiemetic.
- B. Check the client's gastric residual.
- C. Hold the client's feeding.
- D. Reduce the rate of the tube feeding by half.
Correct Answer: C
Rationale: The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate without a provider's order. Checking gastric residual is important but not while the client is vomiting. Continuing to feed the client during vomiting is unsafe.
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.