A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

Stomach contents are yellowish green in color.

Aspirated stomach contents' pH measures 6.5.

Residual volume of stomach contents measures 90 mL.

Hyperactive bowel sounds are present.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Stomach contents are yellowish-green in color is incorrect. While the color of stomach contents might indicate various aspects of digestion or bile presence, a yellowish-green color alone might not necessarily be an immediate cause for concern unless accompanied by other symptoms or indications of a problem.

Choice B Reason:

Aspirated stomach contents' pH measures 6.5 is incorrect. A pH of 6.5 in aspirated stomach contents might indicate a less acidic environment, but it's not usually considered significantly abnormal. However, it's still essential to consider the context and the individual client's situation when interpreting pH values.

Choice C Reason:

Residual volume of stomach contents measures 90 mL is correct. A residual volume of 90 mL is considered high and could indicate delayed gastric emptying or potential issues with the client's ability to tolerate or absorb feedings. Reporting this finding to the provider is essential for further assessment and potential adjustments in the client's care plan.

Choice D Reason:

Hyperactive bowel sounds are present is incorrect. Hyperactive bowel sounds might suggest increased peristalsis or bowel activity. While this finding may be noted and monitored, it might not require immediate reporting unless it's associated with other concerning symptoms or complications.

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Correct Answer is A

Explanation

Choice A Reason:

"I might have headaches due to a decline in my estrogen levels." Is appropriate. During perimenopause, fluctuations and eventual decline in estrogen levels can contribute to various symptoms, including headaches or migraines, due to hormonal changes. This statement reflects an awareness of one of the possible effects of changing hormone levels during this stage.

Choice B Reason:

"The best time to perform a breast self-examination is on the first day of my period." Is not appropriate. While performing a breast self-examination regularly is essential for breast health, the first day of the period isn't necessarily the "best" time for everyone. It's more advisable to choose a consistent day each month that is convenient and easy to remember.

Choice C Reason:

"I can expect to have regular periods until I am in menopause." Is not appropriate. Perimenopause is characterized by irregular periods, which means that during this transitional phase, menstrual cycles often become less predictable in terms of timing, duration, and flow. Irregular periods are a hallmark of perimenopause, so expecting regularity until menopause is not accurate.

Choice D Reason:

"I should stop receiving Papanicolaou tests once I reach menopause." Is not appropriate. Papanicolaou (Pap) tests are essential for detecting cervical abnormalities, regardless of menopausal status. Women should continue to have regular Pap tests according to their healthcare provider's recommendations, as the risk of cervical cancer persists even after menopause.

A. Ask the assist personnel to document the client's time of death. B. Place an identification tag on the outside of the client's shroud. C. Wear sterile gloves when cleaning the client's body. D. Remove the client's dentures and give them to the client's family.

Correct Answer is B

Explanation

A. Asking the assist personnel to document the client's time of death is not correct. While accurate documentation of the time of death is important, the responsibility typically falls on the healthcare provider or physician who confirms the death, not necessarily the assist personnel involved in postmortem care. B. Place an identification tag on the outside of the client's shroud is correct. This action ensures proper identification throughout the postmortem process and aligns with standard procedures for maintaining identification integrity during autopsy procedures. Identifying the client accurately is crucial to prevent any errors or mix-ups. C. Wearing sterile gloves when cleaning the client's body is incorrect. Sterile gloves are not typically required for postmortem care. While gloves are important for infection control, they don't necessarily need to be sterile for handling deceased patients unless there are specific infectious concerns. D. Removing the client's dentures and give them to the client's family is incorrect. In most cases, the client's personal belongings, including dentures, are typically handled according to specific protocols or the family's wishes. However, removing the dentures and giving them to the family isn't typically part of postmortem care. The family might be informed about the presence of dentures and their disposition, but the decision to give them to the family should follow established procedures or the family's preferences.

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A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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