A nurse on a medical-surgical unit knows that for clients with a BMI greater than or equal to 30, it is important to:

Utilize supine positioning to maximize chest expansion.

Use an appropriately sized blood pressure cuff.

Consult a nutritionist because the client is malnourished/underweight.

Place the client on fall precautions because of increased risk for falls due to frail bones.

Answer and Explanation

The Correct Answer is B

Choice A reason: Utilize supine positioning to maximize chest expansion is not an important intervention for clients with a BMI greater than or equal to 30. Supine positioning is when the client lies flat on their back. This position can actually impair chest expansion and breathing for clients with a high BMI, as the weight of the abdomen and chest can compress the lungs and diaphragm. A semi-Fowler's position, where the head of the bed is elevated at 30 to 45 degrees, is preferred for these clients, as it reduces the pressure on the chest and improves ventilation.

Choice B reason: Use an appropriately sized blood pressure cuff is an important intervention for clients with a BMI greater than or equal to 30. A blood pressure cuff that is too small or too tight can cause inaccurate readings and increase the risk of injury to the client. A blood pressure cuff that is too large or too loose can also cause inaccurate readings and compromise the quality of care. A blood pressure cuff that fits the client's arm circumference and width is essential for obtaining accurate and reliable measurements and preventing complications.

Choice C reason: Consult a nutritionist because the client is malnourished/underweight is not an important intervention for clients with a BMI greater than or equal to 30. A BMI greater than or equal to 30 indicates that the client is obese, not malnourished or underweight. Obesity is a condition where the client has excess body fat that can affect their health and well-being. Malnutrition is a condition where the client has inadequate or imbalanced intake of nutrients that can affect their growth and development. Underweight is a condition where the client has a low body weight that can affect their immunity and energy. A nutritionist can help clients with any of these conditions, but the statement is incorrect for clients with a high BMI.

Choice D reason: Place the client on fall precautions because of increased risk for falls due to frail bones is not an important intervention for clients with a BMI greater than or equal to 30. Frail bones are not a common consequence of obesity, but rather of osteoporosis, a condition where the bones become weak and brittle. Obesity can actually increase the bone density and strength, as the bones have to support more weight. However, obesity can increase the risk for falls due to other factors, such as impaired mobility, balance, or coordination. Fall precautions are important for any client who is at risk for falls, but the statement is inaccurate for clients with a high BMI.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer because safety is the second level of Maslow's hierarchy of needs, and it includes the needs for security, stability, protection, and freedom from fear and anxiety. The couple who just lost their house in a fire are likely experiencing a threat to their safety needs, as they have lost their shelter, possessions, and sense of security. The nurse should identify and address their safety needs as a priority, and help them find alternative housing, financial assistance, and emotional support.

Choice B reason: This is not the correct answer because self-actualization is the highest level of Maslow's hierarchy of needs, and it includes the needs for personal growth, fulfillment, and realization of one's potential. The couple who just lost their house in a fire are unlikely to be concerned with their self-actualization needs at this time, as they have more pressing and basic needs to meet. The nurse should focus on their lower-level needs first, before helping them achieve their higher-level needs.

Choice C reason: This is not the correct answer because esteem is the fourth level of Maslow's hierarchy of needs, and it includes the needs for self-respect, confidence, recognition, and appreciation. The couple who just lost their house in a fire may experience a loss of esteem, as they may feel ashamed, helpless, or worthless. However, their esteem needs are not the most urgent or important at this time, as they have more fundamental needs to satisfy. The nurse should support their esteem needs by showing empathy, respect, and encouragement, but not neglect their lower-level needs.

Choice D reason: This is not the correct answer because love and belonging is the third level of Maslow's hierarchy of needs, and it includes the needs for affection, intimacy, friendship, and social acceptance. The couple who just lost their house in a fire may benefit from their love and belonging needs, as they may seek comfort, support, and connection from others. However, their love and belonging needs are not the primary or essential at this time, as they have more basic and vital needs to fulfill. The nurse should facilitate their love and belonging needs by providing a caring and compassionate environment, but not overlook their lower-level needs.

A. Stabilize the object B. Apply anesthetic drops C. Remove the object D. Apply eye ointment

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because stabilizing the object is the priority nursing action for a penetrating eye injury. Stabilizing the object prevents further damage to the eye structures and reduces the risk of infection and bleeding. The nurse should use a protective shield or cup to cover the eye and secure the object in place, and avoid applying any pressure or movement to the eye.

Choice B reason: This is not the correct answer because applying anesthetic drops is not the priority nursing action for a penetrating eye injury. Anesthetic drops may provide some relief from pain and discomfort, but they do not address the underlying problem of the object in the eye. Anesthetic drops should only be used under the direction of a physician, and after the object has been stabilized.

Choice C reason: This is not the correct answer because removing the object is not the priority nursing action for a penetrating eye injury. Removing the object is a surgical procedure that should only be performed by a qualified physician in a sterile environment. Attempting to remove the object by the nurse may cause more harm to the eye and increase the risk of complications.

Choice D reason: This is not the correct answer because applying eye ointment is not the priority nursing action for a penetrating eye injury. Eye ointment may interfere with the visualization and assessment of the eye, and may also contaminate the wound and cause infection. Eye ointment should only be used under the direction of a physician, and after the object has been stabilized.

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A nurse on a medical-surgical unit knows that for clients with a BMI greater than or equal to 30, it is important to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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