The client is weighed each month while residing in the long-term ...

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The client is weighed each month while residing in the long-term care facility. This month the client weighs 110 lb (50 kg). The nurse compares this weight to the last 3 months' results and discovers the client has lost 22 lb (10 kg).
 
  There has been no attempt to lose this weight. How does the nurse interpret this weight loss?
  1. No malnutrition
  2. Mild malnutrition
  3. Moderate malnutrition
  4. Severe malnutrition

Question 2

The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What is the nurse's priority action?
 
  1. Place the client in high Fowler's position.
  2. Turn off the tube feeding.
  3. Assess the client's lung sounds.
  4. Assess the client's bowel sounds.

[Brummell1998]

Answer to Question 1

Correct Answer: 2
Rationale: To calculate the level of nutritional deficit, the nurse first figures the current percentage of usual body weight and then compares that result to nutritional standards. To calculate the percent of usual body weight, divide the current weight by the usual body weight and multiply by 100. In this case, the client is at 91 of usual body weight. Mild malnutrition is 85 to 90, moderate malnutrition is 75 to 84, and severe malnutrition is less than 74. This is particularly important in an unintentional weight loss.

Answer to Question 2

Correct Answer: 2
Rationale 1: This action is not the priority.
Rationale 2: These findings indicate possible aspiration of the feeding. The priority action is to discontinue the feeding to eliminate the amount of material going into the client's lungs. This should be done before any further assessment or client position change is attempted. If it is discovered that there is no aspiration, the tube feeding can be restarted.
Rationale 3: This is not the priority action.
Rationale 4: This is not the priority action.

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