The nurse is performing an initial assessment and notes that the client weighs 186.4 pounds. Six months ago, the client weighed 211.8 pounds. What action by the nurse is appropriate?
A. Ask the client if the weight loss was intentional.
B. Determine if there are food allergies and intolerances.
C. Perform a comprehensive nutritional assessment
D.Perform a rapid bedside blood glucose test
A
The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2. What does this value indicate to the nurse?
A. The client has a health weight
B. The client is underweight
C. The client is obese
D. The client is overweight
C
A nurse is reviewing lab values for several clients. Which value indicates a need for a nutritional assessment?
A. Client with an albumin of 3.5
B. Client with a cholesterol of 142
C. Client with a hemoglobin of 9.8
D. Client with a pre albumin of 28
B
A client receiving a bolus wedding through a small bore nasoduodenal tube. What action by the nurse is the priority?
A. Auscultate lung sounds after each feeding
B. Weigh the client daily on the same scale
C. Check tube placement every 8 hours
D.Check tube placement before each feeding
D
A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action buy the nurse is most appropriate?
A. Administer an antiemetic
B. Check the patient's gastric residual
C. Hold the feeding until the vomiting subsides
D. Reduce the rate of the tube feeding by half
C
The nurse inserts a small - bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement?
A. Assess for carbon dioxide using capnometry.
B. Perform pH testing of gastric fluid
C. Auscultate over the epigastric area
D. Request an x-ray before starting the feeding
D
The nurse is caring for an older client receiving total enteral nutrition via a small - bore nasoduodenal tube. For what priority complication would the nurse assess?
A. intermittent diarrhea
B. Cholecystitis
C. Aspiration pneumonia
D.Peptic Ulcer Disease
C
The nurse is managing care for a client receiving feeding through a gastrostomy tube. What assessment would the nurse perform?
A. Check the skin around the tube insertion site.
B. Weigh the client every shift with the same scale
C. Draw blood to assess albumin every shift
D.Irrigate the tube at least once a day
A
A client is receiving total parenteral nutrition. On Assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56, skin is dry and skin turgor is poor. What action should the nurse perform next?
A. Assess the 24 hour intake and output
B. Assess the client's oral cavity
C. Prepare to hang a normal saline bolus
D. Increase the infusion rate of the TPN.
A
A client who had minimally invasive bypass gastric surgery 2 days ago reports new onset of severe abdominal pain. What is the nurse's best action at this time?
A. Listen to the client's bowel sounds
B. Call the rapid response team
C. Take the clients vital signs
D. Contact the primary health care provider
C
A client just returned to the surgical unit after an open traditional gastric bypass. What action by the nurse is the priority?
A. Assess the patient's pain
B. Check the surgical incision
C. Ensure an adequate airway
D. Program the morphine pump
C
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says, " I didn't know it would be this hard to live like this." What approach by the nurse is best?
A. Assess the client's coping and support systems.
B. Inform the client that things will get easier
C. Red-educate the client on needed dietary changes
D. Tell the client that lifestyle changes are always hard
A
A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for the nurse to provide?
A. Increase the fiber and water in your diet to prevent diarrhea
B. Report any suicidal thoughts to your primary health care provider
C. Report dry mouth and decreased sweating
D. Do not take antibiotics or nay other anti - infective drugs
B
A client is awaiting bariatric surgery in the morning. What action by the nurse is most important?
A. Answering questions the client has about 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
B
The nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to occur? (Select all that apply)
A. Cultural food preferences
B. Family bringing snacks
C. Increased need for nutrition
D. Need for NPO status
E. Staff shortages
A,C,D and E
A nurse has delegated feeding a client to assistive personnel (AP). What actions does the nurse include in the directions to the AP? (Select all that apply.)
A. Allow 30 minutes for eating so food doesn't get spoiled
B. Assess the patient's mouth while providing primal oral care.
C. Ensure that warm and cold items at appropriate temperatures.
D. Remote bedpans, soiled linens, and other unpleasant items
E. Sit with the client, making the atmosphere more relaxed
C,D and E
The nurse is assessing a client who has undernutrition. What signs and symptoms would the nurse expect? (Select all that apply.)
A. Alopecia
B. Stomatitis
C. Muscle wasting
D. Peripheral edema
E. Anemia
F. Dry scaly skin
A,B,C,D,E and F
A client's small - bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.)
A. Attempt to dissolve the clog by instilling a cola product.
B. Determine if any of the medications come in liquid form.
C. Flush the tube before and after administering medications.
D. Mix all medication sin the formula and use a feeding pumo
E.Try to flush the tube with 30 mL of water and gentle pressure.
B,C and E
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 (if worn) for appropriate fit
C. Ensure the client has glasses on or contacts in when eating.
D. Provide salty or high spicy foods that the client can taste
E. Serve high calorie, high protein snacks one to two times a day
A,B,C and E
A postanesthesia care unit (PACU) nurse is assessing a postoperative
client with a nasogastric
(NG) tube. What laboratory values would
warrant intervention by the nurse? (Select all
that
apply.)
a. Blood glucose: 120 mg/dL (6.7
mmol/L)
b. Hemoglobin: 7.8 mg/dL (78 mmol/L)
c. pH:
7.68
d. Potassium: 2.9 mEq/L (2.9 mmol/L)
e. Sodium: 142
mEq/L (142 mmol/L)
B, C, D