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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 A

Explanation

A. Chvostek's sign is a clinical sign observed during physical examination that may indicate hypocalcemia. It is elicited by tapping or lightly striking the facial nerve just anterior to
the earlobe, which can cause twitching of the facial muscles, particularly the muscles around the mouth and nose.
B. This image shows winging of the scapula. Winging of the scapula, also known as
scapular winging, is a condition characterized by the abnormal protrusion or prominence of the scapula away from the back wall of the thorax. Normally, the scapula lies flat
against the rib cage, providing stability and support for arm movements.

A. Inflate the catheter's balloon. B. Lower the penis to a 45° angle. C. Apply lidocaine gel to the urethra. D. Twist the catheter gently.

Correct Answer is D

Explanation

A. Inflating the catheter's balloon is not appropriate when resistance is encountered before reaching the bladder. It could cause trauma or injury.
B. Lowering the penis to a 45° angle may help facilitate catheter insertion initially, but if resistance is encountered, further interventions are needed.
C. Applying lidocaine gel to the urethra may help with discomfort during catheter insertion but will not address the issue of encountering resistance.
D. Twisting the catheter gently can help navigate any obstructions or curves in the urethra. This maneuver should be performed carefully to avoid causing trauma to the urethral mucosa.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign? Image A Image B

Correct Answer is A

Explanation

A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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