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.

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Correct Answer is A

Explanation

Choice A Reason:

"I might have headaches due to a decline in my estrogen levels." Is appropriate. During perimenopause, fluctuations and eventual decline in estrogen levels can contribute to various symptoms, including headaches or migraines, due to hormonal changes. This statement reflects an awareness of one of the possible effects of changing hormone levels during this stage.

Choice B Reason:

"The best time to perform a breast self-examination is on the first day of my period." Is not appropriate. While performing a breast self-examination regularly is essential for breast health, the first day of the period isn't necessarily the "best" time for everyone. It's more advisable to choose a consistent day each month that is convenient and easy to remember.

Choice C Reason:

"I can expect to have regular periods until I am in menopause." Is not appropriate. Perimenopause is characterized by irregular periods, which means that during this transitional phase, menstrual cycles often become less predictable in terms of timing, duration, and flow. Irregular periods are a hallmark of perimenopause, so expecting regularity until menopause is not accurate.

Choice D Reason:

"I should stop receiving Papanicolaou tests once I reach menopause." Is not appropriate. Papanicolaou (Pap) tests are essential for detecting cervical abnormalities, regardless of menopausal status. Women should continue to have regular Pap tests according to their healthcare provider's recommendations, as the risk of cervical cancer persists even after menopause.

A. Stand on the client's stronger side when moving the client into the chair. B. Pivot on the foot farthest from the bed when assisting the client into the chair. C. Flex hips and knees when assisting the client to a standing position. D. Raise the bed to waist level before moving the client.

Correct Answer is C

Explanation

Correct Answer: C

C. Flex hips and knees when assisting the client to a standing position.Flexing the hips and knees protects the nurse’s back by using proper body mechanics and distributes the force of lifting safely. This position provides stability and reduces the risk of injury to both the nurse and the client during the transfer.

Incorrect answers:

A: "Stand on the client's stronger side when moving the client into the chair."The nurse should stand on the weaker side, not the stronger side, to provide support and assistance where it is most needed. This ensures the client is stabilized and prevents falls or instability due to the weaker side giving way.

B: "Pivot on the foot farthest from the bed when assisting the client into the chair."The nurse should pivot on the foot closest to the chair or the bed to maintain balance and stability. Pivoting on the farthest foot could lead to poor body mechanics and an increased risk of injury to the nurse or client.

D: "Raise the bed to waist level before moving the client." For transferring a client to a chair, the bed should be lowered to a position where the client’s feet can touch the floor. This provides stability and facilitates a safe transfer.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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