A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour.
Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L).

24-hour intake at the current infusion rate.

Serum potassium level of 3.1 mEq/L (3.1 mmol/L).

Gastric output of 900 mL in the last 24 hours.

Increased blood urea nitrogen (BUN).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

While it’s important to monitor for any adverse reactions following a vaccination, not all fevers are serious. Mild fever can be a common side effect of vaccinations and is usually not a cause for concern. However, if the child develops a high fever, or if the fever is accompanied by other severe symptoms such as difficulty breathing or extreme lethargy, it should be reported to a healthcare provider immediately.

Choice B rationale:

There is no need to keep the child home from daycare following the Hib vaccine unless the child is feeling unwell or has other symptoms that warrant staying home. The Hib vaccine is not a live vaccine, so the child cannot transmit the vaccine strain to others.

Choice C rationale:

Applying a cool pack to the injection site can help reduce discomfort or swelling that may occur after the vaccination. This is a safe and effective method for managing minor side effects of vaccinations.

Choice D rationale:

Aspirin should not be given to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, over-the-counter pain relievers such as acetaminophen or ibuprofen can be used to help manage any pain or fever following the vaccination, if approved by a healthcare provider. Always follow the dosing instructions on the package and consult with a healthcare provider if unsure.

A. Monitor ETT markings between 22 and 26 cm at teeth line. B. Check for capillary refill of 3 seconds or less. C. Obtain a portable chest x-ray to verify ETT location. D. Assess for symmetrical chest movement. E. Auscultate for presence of bilateral breath sounds.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.

Choice B rationale:

Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.

Choice C rationale:

Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.

Choice D rationale:

Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.

Choice E rationale:

Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.

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Naxlex Comprehensive Predictor Exams

A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

Correct Answer is C

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

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