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 infant has hypoglycemia, which is a low blood glucose level that can cause jitteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.
The other options are not correct because:
A. Offering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.
C. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.
D. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jitteriness.
Correct Answer is C
Explanation
This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.
A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.
B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.
D.Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.
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