Nokea
A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first?
- A. Client with a blood glucose level of 138 mg/dL.
- B. Client with foul-smelling diarrhea.
- C. Client with a potassium level of 2.6 mEq/L.
- D. Client with a sodium level of 138 mEq/L.
Correct Answer: C
Rationale: The potassium level of 2.6 mEq/L is critically low, possibly due to hyperglycemia-induced hyperosmolality. The nurse should see this client first. The blood glucose reading is high but not extreme. The sodium level is normal. The client with diarrhea should be seen last to avoid cross-contamination.
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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 just returned to the surgical unit after bariatric surgery. What is the priority action by the nurse?
- A. Assess the client's pain.
- B. Check the surgical incision.
- C. Ensure a patent airway.
- D. Program the morphine pump.
Correct Answer: C
Rationale: Airway is always the priority, especially in bariatric clients who may have short, thick necks that complicate airway management. The other actions are appropriate but secondary to ensuring a patent airway.
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 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.