A client is admitted for observation with reports of progressively increasing fatigue over the past month and a brief episode of dizziness that occurred today. The client has a history of heartburn and indigestion that is self-treated with ibuprofen and antacids. Which assessment finding should the nurse report immediately to the healthcare provider?

Reference Range:

Guaiac stool [negative]

Hemoglobin (14 to 18 g/dl. (140 to 180 g/L)]

Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]

Gastric Acid pH (1.5 to 3.5)

Positive guaiac of stool.

Hematocrit 42% (0.42 volume fraction).

Gastric pH 2.0.

Hemoglobin 13 g/dL (130 g/L).

Answer and Explanation

The Correct Answer is A

A) Positive guaiac of stool:
A positive guaiac test indicates the presence of occult (hidden) blood in the stool, which may suggest gastrointestinal bleeding. Given the client’s history of heartburn, indigestion, and self-treatment with ibuprofen and antacids, gastrointestinal irritation or ulceration may be occurring, leading to bleeding. Gastrointestinal bleeding can cause fatigue, dizziness, and other symptoms. Therefore, it is essential to report this finding immediately to the healthcare provider for further evaluation and management.

B) Hematocrit 42% (0.42 volume fraction):
A hematocrit level within the reference range (42% to 52%) is considered normal. While a slight decrease in hematocrit may indicate anemia, it is not an urgent finding that requires immediate reporting. The client’s hematocrit level of 42% is within the normal range, so it does not warrant immediate concern.

C) Gastric pH 2.0:
A gastric pH of 2.0 falls within the normal range (1.5 to 3.5) for gastric acid pH. This finding indicates normal gastric acidity and does not suggest an acute problem that requires immediate reporting to the healthcare provider.

D) Hemoglobin 13 g/dL (130 g/L):
A hemoglobin level of 13 g/dL is slightly below the lower end of the reference range (14 to 18 g/dL) but does not indicate a critical condition requiring immediate intervention. While it may suggest mild anemia, it is not an urgent finding that necessitates immediate reporting to the healthcare provider.

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Free Nursing Study Resources

Correct Answer is ["200"]

Explanation

The nurse should program the infusion pump to deliver 200 mL/hr.

Although the medication dosage is 400 mg, the infusion pump rate is determined by the total volume of the IV fluid (including the medication) and the desired infusion time.

In this case:

Total volume of IV bag (D,W): 200 mL

Infusion time: 1 hour

Since the medication is already diluted in the 200 mL bag, the entire volume needs to be delivered over the course of the hour. Therefore, the nurse should program the pump to deliver the full 200 mL of the solution at a rate of:

200 mL / 1 hour = 200 mL/hr

A. Holds the pen in place after the injection. B. Administers into the fleshy outer thigh. C. Cleanses the injection pen for re-use. D. Inserts the injection pen through clothing.

Correct Answer is C

Explanation

A)Holds the pen in place after the injection:
This action is appropriate. Holding the auto-injector pen in place after administering the injection allows the medication to be fully delivered into the muscle. It ensures that the full dose of epinephrine is administered, which is crucial during an emergency situation such as anaphylaxis.

B) Administers into the fleshy outer thigh:
Administering the epinephrine injection into the fleshy outer thigh is the correct technique. The thigh muscle provides a large and accessible area for injection, allowing for rapid absorption of the medication into the bloodstream. This action facilitates the quick onset of epinephrine’s effects, which is vital in treating anaphylaxis.

C) Cleanses the injection pen for re-use:
This action requires intervention by the nurse. Epinephrine auto-injectors are designed for single use only and should not be cleansed or reused. Reusing the injection pen can lead to contamination, incorrect dosing, or malfunction, compromising its effectiveness during subsequent emergencies. It is essential to educate the client that the auto-injector pen is for one-time use only, and a new device should be used if another dose is required.

D) Inserts the injection pen through clothing:
While it is ideal to administer the injection directly onto bare skin, inserting the injection pen through clothing is acceptable in emergency situations when immediate access to bare skin is not possible. The priority during anaphylaxis is administering the epinephrine promptly. However, if feasible, the clothing should be moved aside to allow direct contact of the injection site with the skin for optimal absorption of the medication.

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Naxlex Comprehensive Predictor Exams

A client receives a prescription for ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (D,W) 200 mL. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

Correct Answer is ["200"]

Explanation

The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen. Which client action requires intervention by the nurse?

Correct Answer is C

Explanation

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