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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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Correct Answer is C

Explanation

A. While eventually informing the provider may be necessary, it's important for the nurse to first address the client's concerns directly.
B. Documenting the refusal is important but should occur after addressing the client's concerns.
C. This action allows the nurse to educate the client about the potential risks of not taking the medication, facilitating informed decision-making.
D. Returning the medication is premature until the client's concerns have been addressed and a decision has been made regarding the medication.

A. "There has been too much complaining about these changes." B. "So you are upset about all of the recent changes on the unit?" C. "Why don't you just file a formal complaint with Human Resources?" D. "Please, try to wait a little longer. Things will get better soon."

Correct Answer is B

Explanation

A. Dismissing the employee's concerns by stating there has been too much complaining is not empathetic or supportive.
B. This response acknowledges the employee's feelings and opens the door for further discussion about their concerns, allowing the charge nurse to address them.
C. Suggesting filing a formal complaint with Human Resources may escalate the situation unnecessarily and should not be the initial response.
D. While expressing optimism about the situation may be well-intentioned, it does not address the employee's concerns or offer support.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A charge nurse on a long-term care unit is working with an assistive personnel who states, "I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer." Which of the following responses should the charge nurse make?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client. Exhibits Complete the following sentence: At 1000 the nurse enters the client's room. The first action the nurse should take is dropdownfollowed by dropdown

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