Nokea
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.
You may also like to solve these questions
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.
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.
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.
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 morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate?
- A. Assess the client's readiness to make lifestyle changes.
- B. Leave siderails down to prevent pressure ulcers.
- C. Refer the client to a bariatric center.
- D. Ensure appropriate bariatric equipment is available.
Correct Answer: D
Rationale: Many hospitals that see bariatric-sized clients have appropriate equipment for this population. Ensuring the availability of proper equipment is critical for patient and staff safety. The other options are relevant but not the priority.