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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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. While organ donation may be included in advance directives, it is not the primary purpose of advance directives, which are primarily focused on healthcare decision-making.
B. Advance directives do not require approval from an attorney to be enforced. They are legal documents that become effective once signed by the individual, witness, and, in some cases, notarized.
C. This statement indicates an understanding of the procedural requirement for signing a living will, which typically involves witnesses to ensure its validity.

D. Naming a designee in a durable power of attorney for health care is another aspect of advance directives, but this statement does not address the procedural requirements for signing the
document.

A. The stoma bleeds lightly when touched. B. The stoma is draining a small amount of liquid stool. C. The stoma appears dark in color. D. The stoma protrudes slightly from the abdomen.

Correct Answer is C

Explanation

A. The stoma bleeds lightly when touched: Light bleeding is common postoperatively and may not be concerning unless it's excessive or persistent.
B. The stoma is draining a small amount of liquid stool: This is a normal finding following colostomy placement and is expected in the early postoperative period.
C. The stoma appears dark in color: This may indicate compromised blood supply to the stoma and requires immediate evaluation by the provider.
D. The stoma protrudes slightly from the abdomen: This is a normal finding post-colostomy and does not typically require immediate intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)? Image A B. C. Image B Image C Image D

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?