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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Correct Answer is B

Explanation

Answer: B. Administer a second dose of naloxone.

Rationale:

A) Prepare to assist with chest tube insertion:
Chest tube insertion is not relevant in this situation. A chest tube is typically used for conditions like pneumothorax or pleural effusion, not opioid-induced respiratory depression. The immediate concern here is the opioid overdose and the need for further naloxone administration to reverse the opioid effects, not the placement of a chest tube.

B) Administer a second dose of naloxone:
Administering a second dose of naloxone is the most appropriate action. Naloxone is a short-acting opioid antagonist, and its effects can wear off before the opioids have fully cleared from the client’s system. Given that the client’s respiratory rate is severely depressed and the oxygen saturation is dangerously low, another dose of naloxone is necessary to reverse the opioid's effects and restore adequate breathing. Immediate action is required to prevent further hypoxia.

C) Determine Glasgow Coma Scale score:
While assessing the client’s level of consciousness using the Glasgow Coma Scale (GCS) is important, it is not the immediate priority in this situation. The client’s low respiratory rate and oxygen saturation indicate a critical need for immediate treatment to improve ventilation and oxygenation. Administering naloxone should take precedence over neurological assessment.

D) Initiate cardiopulmonary resuscitation (CPR):
While the client’s respiratory depression is severe, initiating CPR may not yet be necessary if the client still has a pulse. Administering naloxone can potentially reverse the respiratory depression and prevent the need for CPR. If the client's condition continues to decline despite naloxone administration, CPR may become necessary later, but the first step is to administer a second dose of naloxone to restore breathing.

Correct Answer is ["31"]

Explanation

To find out how many gtt/min the nurse should regulate the infusion;

We can use the following formula:

Flowrate(gtt/min) = Totalvolume(mL) / Time(min) × Dropfactor(gtt/mL)

Given:

Total volume = 500 mL

Time = 4 hours = 240 minutes (since 1 hour = 60 minutes)

Drop factor = 15 gtt/mL

Substituting the given values into the formula:

Flowrate(gtt/min) =500mL/240min ×15gtt/mL

After performing the calculation, we find that the flow rate equals 31.25 gtt/min.

So, the nurse should regulate the infusion to 31 gtt/min (rounded to the nearest whole number).

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Naxlex Comprehensive Predictor Exams

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

Correct Answer is B

Explanation

Rationale:

A client receives a prescription for dextrose 5% in water 500 mL IV to be infused over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["31"]

Explanation

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