A male client is admitted for observation because he is reporting progressively increasing fatigue over the past month and a brief episode of dizziness that occurred today. He has a history of heartburn and indigestion that he self-treats with ibuprofen and antacids. Which assessment finding should the nurse report immediately to the healthcare provider?

Reference Ranges:
Hemoglobin (14 to 18 g/dL (8.7 to 11.2 mmol/L)]
Hematocrit [42% to 52% (0.42 to 0.52 volume fraction)]
Gastric pH [1.5 to 3.5]

Hematocrit 42% (0.42 volume fraction).

Hemoglobin 13 g/dL (8.07 mmol/L).

Positive guaiac of stool.

Gastric pH 2.0.

Answer and Explanation

The Correct Answer is C

A. Hematocrit 42% (0.42 volume fraction):
A hematocrit of 42% is within the normal reference range for males (42% to 52%). While it is important to monitor hematocrit levels, this finding alone does not indicate an immediate issue.

B. Hemoglobin 13 g/dL (8.07 mmol/L):
A hemoglobin level of 13 g/dL is slightly below the normal range for males (14 to 18 g/dL). However, it is not critically low and may not require immediate intervention without additional context or symptoms.

C. Positive guaiac of stool:
A positive guaiac test for stool indicates the presence of occult blood in the stool, which could suggest gastrointestinal bleeding. Given the client's history of heartburn, indigestion, and use of ibuprofen (a nonsteroidal anti-inflammatory drug that can cause gastrointestinal bleeding), this finding is concerning and should be reported immediately to the healthcare provider for further evaluation and management.

D. Gastric pH 2.0:
A gastric pH of 2.0 is within the normal range for gastric acid, as the normal pH of gastric acid typically ranges from 1.5 to 3.5. This finding is expected and does not indicate an immediate problem related to the client's symptoms.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A) Check for correct placement of the patch behind the client's ear: While ensuring correct placement is important for the effectiveness of transdermal patches, the scopolamine patch is primarily used for motion sickness and nausea, not for pain relief. Checking placement does not address the client's pain, which is not the intended use of the medication.

B) Explain that the medication is not given to prevent pain: Scopolamine is used to prevent nausea and motion sickness, not to manage pain. The client’s pain is unrelated to the patch’s intended purpose. Educating the client about the medication's purpose and recommending appropriate pain management would address the issue effectively.

C) Advise the client that the effects of the medication have worn off: The scopolamine patch's effects for nausea or motion sickness would not typically wear off within four hours. The medication was not intended to address pain, so advising the client about its effectiveness for nausea rather than pain would be more appropriate.

D) Offer to apply a new transdermal patch to relieve the pain: Applying a new patch would not be effective for pain management, as scopolamine is not designed for pain relief. Instead, the focus should be on addressing the client's pain with suitable analgesics and explaining the purpose of the scopolamine patch.

Correct Answer is ["37.5"]

Explanation

Convert grams to milligrams: 4 grams = 4000 mg

Determine the concentration of magnesium sulfate in the solution: 4000 mg / 500 mL = 8 mg/mL

Calculate the volume needed to deliver 300 mg/hour:

300 mg/hour ÷ 8 mg/mL = 37.5 mL/hour

Therefore, the nurse should set the infusion pump to deliver 37.5 mL/hour.

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Naxlex Comprehensive Predictor Exams

A male client receives a scopolamine transdermal patch 2 hours before surgery. Four hours after surgery, the client tells the nurse that he is experiencing pain and asks why the patch is not working. Which action should the nurse take?

Correct Answer is B

Explanation

The healthcare provider prescribes magnesium sulfate 300 mg/hour IV. The IV bag is contains magnesium sulfate 4 grams in dextrose 5% in water (DW) 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["37.5"]

Explanation

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