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A nurse is assisting in the care of a client.

Nurses' Notes

Day 1:

The client is receiving intermittent tube feedings via a nasogastric tube.

Abdomen is soft, nondistended.

Head of client's bed is positioned to 30° pH of gastric aspirate 4.0

Gastric residual volume is 50 mL Day 2:

Abdomen is distended. Client reports nausea and is coughing.

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Nurses' Notes

Day 2:

Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL

pH of gastric aspirate 4.5 Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.

Choices

Nurses' Notes Day 2:

Abdomen is distended. Client reports nausea and is coughing

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

Distended abdomen

Reports nausea and coughing

Gastric residual volume

Heart rate 110/min

Respiratory rate 24/min

pH of gastric aspirate 4.5

Temperature 37° C (98.6° F)

Answer and Explanation

Correct Answer : A,B,C,D,E

In the scenario provided, the nurse should take further action based on the following findings: The client's distended abdomen, reports of nausea, and coughing suggest possible intolerance to the tube feedings or another complication. A gastric residual volume of 550 mL is significantly higher than the standard safe limit of 500 mL, indicating delayed gastric emptying or feeding intolerance. The pH of gastric aspirate at 4.5 is within normal limits, suggesting that the tube is likely placed correctly. However, the elevated heart rate of 110/min could be a response to discomfort or underlying stress. The pulse oximetry reading of 90% on room air is below the normal range, which typically is 95-100%, indicating potential impaired gas exchange or early signs of respiratory distress. These findings warrant immediate nursing interventions and possibly a reassessment of the feeding regimen, along with measures to improve the client's respiratory function and comfort. It is essential to monitor for further signs of aspiration, respiratory distress, or other complications, and to communicate these findings to the healthcare team for appropriate management.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This response acknowledges the client's decision and expresses concern for their well-being and the potential impact on their loved ones. It also opens the door for the client to discuss their decision-making process and receive support in communicating their decision to others.

B. This response may be perceived as judgmental or dismissive of the client's autonomy and decision-making capacity. It does not provide support or address the client's emotional or psychosocial needs.
C. Delaying the discussion may leave the client feeling unsupported or uncertain about their
decision. It's important to address the client's concerns and provide support in a timely manner.

D. This response minimizes the client's concerns and does not offer support or encouragement for discussing their decision with loved ones. It may also convey a lack of empathy or
understanding of the client's situation.

A. Prepare a dry work surface above the waist level. B. Open the outside cover of the sterile kit and remove the dust cover. C. Grasp the outermost flap of the sterile kit while opening away from the body. D. Open each side flap of the sterile kit individually while pulling to the side. E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.

Correct Answer is A, B, C, D, E

Explanation

To set up a sterile field for changing a dressing on an abdominal wound, the nurse should perform the following steps in sequence: First, prepare a dry work surface above waist level to ensure that the sterile field is maintained at a height that minimizes the risk of contamination. Next, open the outside cover of the sterile kit and carefully remove the dust cover, which protects the inner contents from contamination. Then, grasp the outermost flap of the sterile kit and open it away from the body, avoiding any abrupt movements that could compromise sterility. After that, open each side flap of the sterile kit individually, pulling them to the side and making sure not to reach over the sterile field. Finally, open the innermost lower flap of the sterile kit while standing away from the sterile field to prevent contamination from the nurse's clothing or body. These steps help maintain the sterility of the dressing and the instruments, which is crucial for preventing infection at the wound site.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A, B, C, D, E

Explanation

48. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?

A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?