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A nurse is assisting in the care of a client.

Nurses' Notes

Day 1:

The client is receiving intermittent tube feedings via a nasogastric tube.

Abdomen is soft, nondistended.

Head of client's bed is positioned to 30° pH of gastric aspirate 4.0

Gastric residual volume is 50 mL Day 2:

Abdomen is distended. Client reports nausea and is coughing.

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Nurses' Notes

Day 2:

Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL

pH of gastric aspirate 4.5 Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.

Choices

Nurses' Notes Day 2:

Abdomen is distended. Client reports nausea and is coughing

Gastric residual volume 550 mL pH of gastric aspirate 4.5

Vital Signs

Day 2:

Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min

Pulse oximetry 90% on room air

Distended abdomen

Reports nausea and coughing

Gastric residual volume

Heart rate 110/min

Respiratory rate 24/min

pH of gastric aspirate 4.5

Temperature 37° C (98.6° F)

Answer and Explanation

Correct Answer : A,B,C,D,E

In the scenario provided, the nurse should take further action based on the following findings: The client's distended abdomen, reports of nausea, and coughing suggest possible intolerance to the tube feedings or another complication. A gastric residual volume of 550 mL is significantly higher than the standard safe limit of 500 mL, indicating delayed gastric emptying or feeding intolerance. The pH of gastric aspirate at 4.5 is within normal limits, suggesting that the tube is likely placed correctly. However, the elevated heart rate of 110/min could be a response to discomfort or underlying stress. The pulse oximetry reading of 90% on room air is below the normal range, which typically is 95-100%, indicating potential impaired gas exchange or early signs of respiratory distress. These findings warrant immediate nursing interventions and possibly a reassessment of the feeding regimen, along with measures to improve the client's respiratory function and comfort. It is essential to monitor for further signs of aspiration, respiratory distress, or other complications, and to communicate these findings to the healthcare team for appropriate management.

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Correct Answer is C

Explanation

A. Simple face mask: This can deliver oxygen at flow rates of 5-10 liters per minute and typically provides an oxygen concentration of about 35-50%.

B. Nasal prongs: Nasal prongs deliver oxygen at lower flow rates and may not be sufficient to raise the client's oxygen saturation to 90%.

C. Non-rebreather mask: This mask can deliver high concentrations of oxygen (up to 90-100%) at flow rates of 10-15 liters per minute. It has one-way valves to prevent the patient from rebreathing exhaled air, thus maximizing the delivery of oxygen.

D. Nasal cannula: Nasal cannulas deliver oxygen at lower flow rates (typically up to 6 liters per minute) and may not provide the necessary concentration to achieve an oxygen saturation of 90%.

A. Bowling B. Walking C. Passive range-of-motion exercise D. Jogging

Correct Answer is B

Explanation

A. Bowling: While bowling involves some physical activity, it may not provide sufficient weight-bearing exercise needed to strengthen bones.
B. Walking: Walking is a weight-bearing exercise that helps improve bone density, making it an ideal recommendation for someone at risk for osteoporosis.
C. Passive range-of-motion exercise: While beneficial for maintaining joint flexibility,

passive range-of-motion exercise does not provide the same bone-strengthening benefits as weight-bearing exercises like walking.
D. Jogging: Jogging is higher-impact and may not be suitable for all older adults, especially those at risk for osteoporosis, due to the risk of injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?

Correct Answer is B

Explanation

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