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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.
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A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Designating quiet time so the client can rest.
- B. Ensuring side rails are not causing pressure.
- C. Providing oral care before and after meals and snacks.
- D. Relaying any reports of pain to the registered nurse.
Correct Answer: B
Rationale: When dealing with an obese client, the staff should ensure side rails are not putting pressure on the client's tissues to prevent pressure ulcers. The other options are appropriate but not the priority for comfort.
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 client is in the family practice clinic. Today the client weighs 180.4 pounds (84.7 kg). Six months ago, the client weighed 201.8 pounds (96.2 kg). What action by the nurse is best?
- A. Ask the client if the weight loss was intentional.
- B. Determine if there are food allergies or intolerances.
- C. Determine if there are food allergies or intolerance.
- D. Perform a rapid bedside blood glucose test.
Correct Answer: A
Rationale: This client has had 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on the risk factors, a blood glucose test may be warranted.
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 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.