A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

Stomach contents are yellowish green in color.

Aspirated stomach contents' pH measures 6.5.

Residual volume of stomach contents measures 90 mL.

Hyperactive bowel sounds are present.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Stomach contents are yellowish-green in color is incorrect. While the color of stomach contents might indicate various aspects of digestion or bile presence, a yellowish-green color alone might not necessarily be an immediate cause for concern unless accompanied by other symptoms or indications of a problem.

Choice B Reason:

Aspirated stomach contents' pH measures 6.5 is incorrect. A pH of 6.5 in aspirated stomach contents might indicate a less acidic environment, but it's not usually considered significantly abnormal. However, it's still essential to consider the context and the individual client's situation when interpreting pH values.

Choice C Reason:

Residual volume of stomach contents measures 90 mL is correct. A residual volume of 90 mL is considered high and could indicate delayed gastric emptying or potential issues with the client's ability to tolerate or absorb feedings. Reporting this finding to the provider is essential for further assessment and potential adjustments in the client's care plan.

Choice D Reason:

Hyperactive bowel sounds are present is incorrect. Hyperactive bowel sounds might suggest increased peristalsis or bowel activity. While this finding may be noted and monitored, it might not require immediate reporting unless it's associated with other concerning symptoms or complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Asking the assist personnel to document the client's time of death is not correct. While accurate documentation of the time of death is important, the responsibility typically falls on the healthcare provider or physician who confirms the death, not necessarily the assist personnel involved in postmortem care. B. Place an identification tag on the outside of the client's shroud is correct. This action ensures proper identification throughout the postmortem process and aligns with standard procedures for maintaining identification integrity during autopsy procedures. Identifying the client accurately is crucial to prevent any errors or mix-ups. C. Wearing sterile gloves when cleaning the client's body is incorrect. Sterile gloves are not typically required for postmortem care. While gloves are important for infection control, they don't necessarily need to be sterile for handling deceased patients unless there are specific infectious concerns. D. Removing the client's dentures and give them to the client's family is incorrect. In most cases, the client's personal belongings, including dentures, are typically handled according to specific protocols or the family's wishes. However, removing the dentures and giving them to the family isn't typically part of postmortem care. The family might be informed about the presence of dentures and their disposition, but the decision to give them to the family should follow established procedures or the family's preferences.

A. Recheck the client's SaO, level after having the client cough and clear their throat. B. Review the client's most recent Sao, level in the medical record. C. Notify the charge nurse of the client's condon. D. Check the client's medical records to see which medications were recently administered.

Correct Answer is A

Explanation

Choice A Reason:

Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.

Choice B Reason:

Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.

Choice C Reason:

Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.

Choice D Reason:

Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)

A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends." Which of the following is an appropriate response by the nurse?

A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?