A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.
Complete the following sentence by selecting the most appropriate actions based on the client’s current status.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
The nurse should first: Response 1: Notify the primary health care provider immediately.
This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.
Then, the nurse should: Response 2: Start an IV line for potential medication administration.
Starting an IV line ensures that the client can receive any necessary medications quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hyperactive bowel sounds indicate increased gastrointestinal activity, often associated with conditions like gastroenteritis or diarrhea. While it requires monitoring, it is not immediately concerning in the context of administering medications via a gastrostomy tube.
Choice B rationale
Yellowish-green stomach contents suggest the presence of bile, a normal finding in gastric aspirates. It indicates that the tube is correctly placed in the stomach, which is crucial before administering medications.
Choice C rationale
A pH of 6.5 for aspirated stomach contents suggests that the tube might be dislocated into the respiratory tract or intestines, as normal gastric pH ranges from 1.5 to 3.5. Reporting this finding is critical to avoid complications.
Choice D rationale
A residual volume of 90 mL is within the acceptable range for most clients with gastrostomy tubes. High residual volumes (usually over 200 mL) are more concerning and may require intervention.
Correct Answer is A
Explanation
Choice A rationale
Avoid placing toilet tissue in the bedpan after defecation to prevent contamination of the stool specimen. Toilet tissue can introduce foreign substances that may interfere with lab results.
Choice B rationale
Urinate after the specimen collection is incorrect because urine can contaminate the stool sample. The client should urinate before collecting the stool specimen to avoid mixing the two.
Choice C rationale
Placing 1.3 cm (0.5 in) of formed stool into a culture tube is insufficient for a proper stool sample. Typically, a larger sample is needed to ensure enough material is available for testing.
Choice D rationale
Keeping the specimen in a warm area is incorrect because stool samples should be kept in a cool environment to preserve the integrity of the specimen until it can be analyzed.
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