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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.
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A client is receiving bolus feedings through a Dobbloff tube. What action by the nurse is most important?
- A. Auscultate lung sounds after each feeding.
- B. Check tube placement before each feeding.
- C. Check tube placement every 8 hours.
- D. Weigh the client daily on the same scale.
Correct Answer: B
Rationale: For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will not prevent misplacement issues. Weighing the client is important to determine if nutritional goals are being met.
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 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 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.