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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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.

B. The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.

C. Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.

D. Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.

A. Removing the client's dentures from their mouth B. Washing the client's face C. Closing the client's eyes D. Gathering the client's personal belongings

Correct Answer is A

Explanation

A. Removing the client's dentures should be performed by a licensed nurse rather than an assistive personnel to ensure proper handling and documentation.
B. Washing the client's face is appropriate postmortem care.
C. Closing the client's eyes is appropriate postmortem care.
D. Gathering the client's personal belongings is appropriate postmortem care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?

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?

A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?

A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?

A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?

A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?