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. Applying restraints over clothing helps to prevent direct skin contact, which can reduce the risk of skin irritation, abrasions, and pressure sores that might occur from prolonged contact with the restraint material. It also serves as a layer of padding, offering additional comfort for the patient. Moreover, clothing can act as a barrier against potential constriction of blood flow or nerve compression.
B. Two fingers should fit between the restraint and the client's body and not four fingers. This helps prevent excessive tightness, which can lead to restricted circulation and skin breakdown. This action promotes client safety and comfort.
C. Checking the client's skin integrity should be done done more frequently than the four hours to assess for any skin damage or irritation.
D. Tying the belt restraint to the side rail of the bed may pose a safety risk, as it could restrict the client's movement and lead to injury or discomfort. The belt restraint should be anchored to an immobile part of the bed.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
|
Provider prescription |
Expected |
Unexpected |
|
Home health evaluation of home safety |
X |
|
|
Vitamin D supplement 2,500 units daily |
X |
|
|
Vitamin D supplement 2,500 units daily |
X |
|
|
Increase caffeine intake |
X |
|
Physical therapy for muscle- strengthening and balance- training |
X |
|
|
Increase daily sun exposure |
X |
- Home health evaluation of home safety: Expected, as it can help prevent falls, which are a significant risk for patients with osteoporosis due to increased fracture risk.
- Vitamin D supplement 2,500 units daily: Expected, since Vitamin D is essential for calcium absorption and bone health, and supplementation is commonly recommended for osteoporosis patients.
- Calcium 1500 mg po once daily on an empty stomach: Expected, because adequate calcium intake is crucial for maintaining bone density and overall bone health.
- Increase caffeine intake: Unexpected, as excessive caffeine can interfere with calcium absorption and exacerbate bone density loss.
- Physical therapy for muscle-strengthening and balance-training: Expected, to improve muscle strength, balance, and coordination, which can help reduce the risk of falls and subsequent fractures.
- Increase daily sun exposure: Expected, but with caution. While sun exposure helps with Vitamin D synthesis, it should be balanced with skin cancer risk, especially in older adults.
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