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 is a responsibility of the nurse in the process of informed consent, which is the patient’s choice to have a treatment or procedure based on their full understanding of its benefits, risks, and alternatives. The nurse should provide written materials in the client’s spoken language, when possible, and verify that the client comprehends and consents to the care and procedures.
Choice A is wrong because confirming that the client is competent to sign for the procedure is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only obtain consent when initiating care or reviewing consent before providing care ordered by another health professional.
Choice B is wrong because discussing the risks of the procedure with the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.
Choice D is wrong because explaining alternatives to the procedure to the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.
Correct Answer is A
Explanation
This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.
Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.
Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.
Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.
Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.
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