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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.
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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 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 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 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.