A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Temperature 38.2° C (100.8° F)

Hematocrit 45%

Respiratory rate 12/min

Urine specific gravity 1.015

Answer and Explanation

The Correct Answer is A

A.   This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B.   Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C.   A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D.   Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

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Correct Answer is B

Explanation

A. Gelatin is derived from collagen obtained from various animal body parts. It is commonly used in medications, including some capsules and intravenous (IV) preparations. It has no association with cardiac catheterization procedure.
B. This is because the contrast dye used during the procedure typically contains iodine, which can cause an allergic reaction in susceptible individuals.
C. Yeast allergies are reactions to proteins found in yeast, commonly used in baking and brewing and sometimes present in vaccines and medications. However, it has no association with cardiac catheterization procedure.
D. Egg allergies involve reactions to proteins found in eggs and can be present in vaccines, some medications, and some foods. However, it has no association with cardiac catheterization procedure.

A. Avoid applying pressure to the tragus of the ear. B. Don sterile gloves to instill the medication C. Pull the pinna upward and backward. D. Chill the otic solution prior to administration.

Correct Answer is C

Explanation

A. The tragus is a small projection of cartilage in front of the ear canal. Applying gentle pressure to the tragus after instilling ear drops helps to facilitate the passage of the drops into the ear canal. This action should not be avoided; rather, it is recommended to enhance the delivery of the medication.
B. Sterile gloves are not typically necessary for instilling ear drops unless the client has an open or infected ear canal. Using clean, non-sterile gloves or practicing proper hand hygiene is sufficient to maintain cleanliness during the procedure.
C. For an adult client, pulling the pinna (outer ear) upward and backward helps to straighten the ear canal. This allows the drops to flow easily into the ear canal rather than pooling in the outer ear or leaking out. This technique ensures that the medication reaches the target area effectively.
D. Chilling otic (ear) solutions is not recommended unless specifically instructed by the healthcare provider for therapeutic reasons (e.g., to soothe ear pain or inflammation). Cold solutions can cause discomfort or dizziness when instilled into the ear. Therefore, otic solutions are typically administered at room temperature to avoid these adverse effects.

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A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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