Nutrition: Test Bank Go – Chapter 60 – Flashcards
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A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best?
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Ask the client if the weight loss was intentional. This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.
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A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding?
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Specific lack of protein Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition.
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A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority?
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Cholesterol: 142 mg/dL 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 prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.
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A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important?
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Check tube placement before each feeding. 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 indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met.
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A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?
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Hold the feeding until the nausea subsides. 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. After vomiting, a gastric residual will not be accurate. The nurse should not continue to feed the client while he or she is vomiting.
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A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity?
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Administer free-water boluses. Proteins and sugar molecules in the enteral feeding product contribute to dehydration due to increased osmolarity. The nurse can administer free-water boluses after consulting with the provider on the appropriate amount and timing of the boluses, or per protocol. The client may not be able to switch formulas. Diluting the formula is not appropriate. Slowing the rate of the infusion will not address the problem.
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A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first?
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Client with a potassium level of 2.6 mEq/L The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this client first. The blood glucose reading is high, but not extreme. The sodium is normal. The client with the diarrhea should be seen last to avoid cross-contamination.
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A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition?
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Client with congestive heart failure Clients receiving PPN typically get large amounts of fluid volume, making the client with heart failure a poor candidate. The other candidates are appropriate for this type of nutritional support.
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A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next?
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Assess the 24-hour fluid balance. This client has clinical indicators of dehydration, so the nurse calculates the clients 24-hour intake, output, and fluid balance. This information is then reported to the provider. The clients oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The clients dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action.
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A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority?
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Psychosocial influences on weight While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the clients psychosocial status as the priority.
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A client asks the nurse about drugs for weight loss. What response by the nurse is best?
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There are three drugs currently approved for this. There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine-topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation.
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A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?
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Ensure an adequate airway. All actions are appropriate care measures for this client; however, airway is always the priority. Bariatric clients tend to have short, thick necks that complicate airway management.
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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?
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Ensure adequate staff when moving the client
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A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didnt know it would be this hard to live like this. What response by the nurse is best?
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Assess the clients coping and support systems.
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A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate?
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Increase the fiber and water in your diet.
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Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the clients record because I just have to know how much she weighs! What action by the clients nurse is most appropriate?
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State That is a violation of client confidentiality.
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A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate?
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Fill out and file a variance report.
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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)?
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Ensuring siderails are not causing excess pressure
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A client is awaiting bariatric surgery in the morning. What action by the nurse is most important?
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Beginning venous thromboembolism prophylaxis
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A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important?
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Performing appropriate hand hygiene
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A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this clients height?
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Use knee-height calipers.
