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Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because'I just have to know how much she weighs.' What action by the client's nurse is most appropriate?
- A. Make an anonymous report to the charge nurse.
- B. State,'That is a violation of client confidentiality.'
- C. Walk away and ignore the other nurse's behavior.
- D. Document the incident in the client's chart.
Correct Answer: B
Rationale: Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.
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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 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.
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.
When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.)
- A. Allow uninterrupted time for eating.
- B. Assess dentures for appropriate fit.
- C. Ensure the client wears glasses if needed.
- D. Provide daily foods that the client can taste.
- E. Serve high-calorie, high-protein snacks.
Correct Answer: A,B,C,E
Rationale: Older adults need unhurried and uninterrupted time for eating. Dentures and glasses, if needed, should fit appropriately. High-calorie, high-protein snacks are beneficial. Salty snacks are not recommended due to sodium restrictions.
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.