A nurse is caring for an older adult client who has a hearing aid.Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

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.

Choice A rationale

Placing a thick layer of stool on the specimen card is incorrect. For fecal occult blood testing, a thin smear of stool is needed to accurately detect any hidden blood. A thick layer can obscure the test results and lead to false negatives.

Choice B rationale

Urinating prior to collecting the stool specimen is essential to prevent contamination. Urine can dilute the stool sample, potentially affecting the accuracy of the fecal occult blood test results.

Choice C rationale

Discontinuing supplements containing vitamin C 24 hours before the test is crucial. Vitamin C can interfere with the chemical reaction in fecal occult blood tests, leading to false-negative results by reducing the detectable levels of hemoglobin.

Choice D rationale

Refraining from consuming pork 7 days before the test is important because certain foods, including red meat like pork, can contain animal hemoglobin, potentially causing false-positive results in fecal occult blood tests.