A physician orders a nasogastric (NG) tube for a young adult diagnosed with end-stage ovarian cancer and suspected of having a bowel obstruction. The newly hired nurse explains the procedure and rationale for NG tube placement. The client refuses to consent to NG tube placement, stating, "I would rather keep vomiting than have the tube in my nose." Following the American Nurses Association Code of Ethics for Nurses, what should the nurse do next?

Delegate the NG tube placement to a more experienced nurse.

Make a referral to Social Services related to body image disturbance.

Seek the client's spouse for consent to the procedure.

Document the client's wishes and notify the physician.

Answer and Explanation

The Correct Answer is D

Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.

Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.

Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.

Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.

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Correct Answer is A

Explanation

Choice A reason : In end-stage kidney disease, the kidneys are unable to excrete excess fluid, leading to fluid overload or hypervolemia. This condition can manifest as shortness of breath due to pulmonary edema, swelling in the lower extremities, and crackles in the lungs upon auscultation. Elevated blood pressure is also a common finding in hypervolemia due to the increased volume of fluid in the bloodstream⁵⁶⁷⁸.

Choice B reason : Hypovolemia, or decreased blood volume, is not consistent with the symptoms described. It typically presents with signs of dehydration, low blood pressure, and tachycardia, which are not mentioned in the client's manifestations.

Choice C reason : Hyponatremia, or low sodium levels in the blood, can occur in ESKD due to dilution from retained fluids, but the primary symptoms described by the client are more indicative of fluid overload rather than electrolyte imbalance alone.

Choice D reason : Hyperkalemia, or high potassium levels, is a serious complication of ESKD due to the kidneys' inability to excrete potassium. While it is a concern in ESKD, the symptoms described by the client are more directly related to fluid overload.

A. Administer Albuterol 2 puffs stat. B. Administer an injection of epinephrine stat. C. Administer high-residual cannula. D. Administer 5 mg prescription of the bee.

Correct Answer is B

Explanation

Choice A reason : Albuterol is a bronchodilator often used in asthma to relieve symptoms of bronchospasm. While it can help open airways, in a case of anaphylaxis, it does not address the systemic histamine release and is not the first-line treatment¹.

Choice B reason : Epinephrine is the primary treatment for anaphylaxis, which is a severe allergic reaction that can occur after a bee sting. It works rapidly to improve breathing, stimulate the heart, reverse hives, and reduce swelling of the face, lips, and throat¹³. In an emergency situation where a patient is experiencing anaphylactic symptoms such as difficulty breathing and a feeling of a lump in the throat, immediate administration of epinephrine is critical to counteract the reaction.

Choice C reason : The term "high-residual cannula" does not correspond to a recognized medical treatment or device. In the context of anaphylaxis, oxygen may be administered via a high-flow nasal cannula if the patient is experiencing respiratory distress, but this would be secondary to the administration of epinephrine.

Choice D reason : The option "Administer 5 mg prescription of the bee" is nonsensical as it does not refer to a legitimate medical treatment. In the context of bee stings, no medication is prescribed as "prescription of the bee."

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

A nurse is providing teaching for a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates the need for further teaching?

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

A nurse is reviewing the laboratory results of a client who has liver failure with ascites and is receiving spironolactone. Which of the following findings should the nurse expect?

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain?

A nurse is teaching a client about self-administered peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?

A nurse is assessing a client who has myxedema coma. Which of the following findings should the nurse expect?