The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermitent suction. The client reports dizziness and tingling in digits. Which assessment finding by the PN should be reported to the healthcare provider?
Hyperactive bowel sounds on assessment.
Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry.
Hypoactive bowel sounds on assessment.
Regular heart rate of 100 beats per minute on telemetry.
The Correct Answer is B
PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.
The other options are not correct because:
A. Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.
C. Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after bowel surgery and do not require immediate intervention.
D. Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Notify the charge nurse of the client's concerns about surgery. Choice A rationale:
Reminding the client that the consent has already been obtained does not address the client's current fears and uncertainty about undergoing the surgery. It may come across as dismissive and unsupportive of the client's emotional needs.
Choice B rationale:
This is the correct answer because notifying the charge nurse of the client's concerns about surgery allows the nursing team to provide the necessary support and address the client's emotional needs appropriately. The charge nurse can assess the client's anxiety level, discuss the procedure, and involve the healthcare provider if needed to ensure the client is well-
informed and comfortable with their decision. Choice C rationale:
Documenting the client's expressed concerns about the surgery is essential for accurate documentation but does not provide the immediate support and intervention the client may require.
Choice D rationale:
Encouraging the client to continue with the scheduled surgery without addressing their fears and uncertainty may not be appropriate. The client's emotional well-being should be a priority, and they should feel supported in their decision-making process.
Correct Answer is D
Explanation
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
A. Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.
B. Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.
C. Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of fluid status.
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