A nurse is caring for a patient with a BMI of.
Appropriate nursing interventions include:
Hourly vital signs.
Implementing all fall risk precautions.
Utilizing bariatric bed and trapeze bar.
Supine positioning.
The Correct Answer is C
A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.
These interventions can promote comfort, safety, and independence for the patient.
Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.
Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.
Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.
The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.
Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.
Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.
Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.
Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.
Correct Answer is D
Explanation
A client with chronic bronchitis is expected to have a cough that produces sputum for at least 3 months during two successive years. This is due to the hyperplasia of mucous glands and bronchial wall inflammation that occur in chronic bronchitis.
Choice A is wrong because SpO2 >92% is not a specific finding for chronic bronchitis.
SpO2 is a measure of oxygen saturation in the blood and can vary depending on many factors, such as altitude, smoking, and lung diseases. SpO2 may be lower than normal in COPD patients due to airflow obstruction and impaired gas exchange.
Choice B is wrong because underweight is not a typical finding for chronic bronchitis.
Underweight may be more associated with emphysema, which is another component of COPD that involves the destruction of alveolar walls and enlargement of air spaces. Emphysema can cause weight loss due to increased work of breathing and decreased appetite.
Choice C is wrong because bradypnea is not a common finding for chronic bronchitis.
Bradypnea is abnormally slow breathing rate and can be caused by various conditions, such as brain injury, drug overdose, or sleep apnea. Chronic bronchitis usually causes tachypnea, which is abnormally fast breathing rate, due to hypoxia and hypercapnia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.