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)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Severe wheezing indicates a potential allergic reaction or anaphylaxis to the IV antibiotics, which requires immediate intervention. It can compromise the client's respiratory function and may lead to respiratory arrest if not promptly addressed.
B. Rhinitis, or inflammation of the nasal passages, is not typically associated with IV antibiotic administration and is not a life-threatening emergency.
C. Small, raised vesicles over the body may indicate a rash or allergic reaction, but unless accompanied by other severe symptoms such as difficulty breathing or systemic signs of anaphylaxis, it does not require immediate reporting.
D. Itching of the skin may indicate a mild allergic reaction, but unless accompanied by more severe symptoms, it does not require immediate reporting.
Correct Answer is B
Explanation
A. Using overhead lighting can disrupt the client's sleep by increasing stimulation; instead, use minimal lighting during nighttime assessments.
B. Keeping the door to the client's room closed can help reduce noise and disturbances from the hallway, promoting a more conducive sleep environment.
C. Providing snug-fitting nightwear may not directly address the underlying causes of insomnia and might not be effective for all clients.
D. Administering diuretics in the evening may exacerbate nocturia and disrupt sleep patterns; instead, diuretics are typically given earlier in the day to minimize nighttime urination.
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