The nurse is evaluating the arterial blood gas and vital signs of a client admitted with abdominal pain of unknown etiology who has a nasogastric tube draining green bile.

Which action should the nurse take first?

Assess the client to rule out any complications secondary to the client's pain.

Administer intravenous sodium bicarbonate to the client.

Determine the last time the client was medicated for abdominal pain.

Check the amount of suction on the client's nasogastric tube.

Answer and Explanation

The Correct Answer is D

Metabolic alkalosis results from the excessive loss of gastric hydrochloric acid during prolonged nasogastric suctioning or emesis. This depletion of hydrogen ions causes a rise in serum pH and an accumulation of bicarbonate ions, shifting the acid-base balance toward alkalinity. Compensatory mechanisms include hypoventilation to retain carbon dioxide, though this is often limited by the body’s physiological requirement for oxygenation.

Rationale:

A. While assessing for complications of pain is a standard nursing responsibility, the objective data indicates a primary metabolic imbalance that must be addressed at its source. Pain typically causes respiratory alkalosis via hyperventilation, but this client's PaCO2 is within normal limits, suggesting the pain is not the cause of the pH shift. Clinical priority must remain on the most likely cause of the alkalotic state.

B. Administering intravenous sodium bicarbonate is strictly contraindicated as it would further elevate the pH and worsen the metabolic alkalosis. Sodium bicarbonate is used to treat metabolic acidosis, and its administration in this scenario could lead to severe tetany or cardiac arrhythmias. The nurse must recognize that the client already has an excess of base bicarbonate in their system.

C. Medicating the client for pain is an important comfort measure, but the priority is to stop the pathological loss of electrolytes and acid. A heart rate of 103 bpm with a new U wave is a classic sign of hypokalemia, which frequently accompanies metabolic alkalosis from gastric suctioning. Determining the last dose of analgesia does not address the imminent cardiac risk associated with electrolyte depletion.

D. Checking the suction level is the first action to prevent further gastric acid depletion and stabilize the metabolic state. Excessive or continuous suctioning is the direct cause of the elevated pH and bicarbonate levels seen in this client’s ABG report. Adjusting the suction to the prescribed intermittent or low setting is the primary intervention to halt the hydrochloric acid loss.

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Correct Answer is A

Explanation

Influenza is an acute viral respiratory infection caused by influenza A or B viruses, transmitted primarily via respiratory droplets and contaminated hands/fomites. Prevention strategies focus on reducing viral transmission through interruption of contact spread, aerosol exposure, and enhancement of hand hygiene compliance alongside immunization.

Rationale:

A. Frequent hand hygiene is the most effective preventive measure because influenza spreads significantly through fomite transmission and self-inoculation via mucous membranes. Proper handwashing with soap mechanically removes viral particles, reducing infection risk more effectively than environmental control measures alone.

B. Minimizing exposure to crowds reduces droplet transmission risk, but it is not always feasible in community or school settings. It is a secondary preventive strategy and less effective than direct interruption of viral transfer through hand hygiene practices.

C. Disinfecting toys reduces fomite contamination, but influenza transmission is primarily respiratory rather than gastrointestinal. While useful in reducing general pathogen spread, it is less impactful than hand hygiene in preventing influenza infection.

D. Washing foods and produce targets foodborne pathogens, not influenza virus transmission. Influenza is not transmitted via ingestion of contaminated food. Therefore, this measure is irrelevant to influenza prevention and does not address the primary transmission pathway.

A. The review-of-literature article that cited ambiguous statistics about the product. B. The article in which the study was conducted by the manufacturer of the product used. C. The research article included 10 subjects participating in the study. D. The review-of-literature article that cited numerous studies supporting the product

Correct Answer is D

Explanation

Evidence-based practice (EBP) relies on the hierarchical synthesis of clinical research to validate procedural changes and improve patient outcomes. Systematic reviews and meta-analyses occupy the highest levels of the evidence pyramid, providing a rigorous evaluation of multiple studies. This approach minimizes sampling bias and ensures that nursing interventions are grounded in statistically significant, reproducible scientific data.

Rationale:

A. Ambiguous statistics indicate a lack of statistical significance or clarity in the research findings, making the data unreliable for clinical application. Evidence used to change hospital policy must demonstrate internal validity and clear, consistent results to ensure patient safety. Articles with vague or conflicting data cannot justify a shift in standardized protocols.

B. Research conducted by the manufacturer presents a significant conflict of interest, which can compromise the objectivity of the study results. Independent, peer-reviewed research is necessary to eliminate commercial bias and ensure the product’s efficacy is evaluated neutrally. Trustworthy EBP requires findings that are free from financial influence or industry-driven motives.

C. A study with only 10 subjects has an inadequate sample size, which severely limits the generalizability of the findings to a broader population. Small cohorts lack the statistical power required to prove that results are not due to mere chance. For central line care, robust data from large, multi-center trials are essential to mitigate clinical risks.

D. A review-of-literature that synthesizes numerous studies represents a systematic approach to evidence, offering the strongest support for a new procedure. These articles aggregate diverse data points to confirm the clinical efficacy and safety of a product across various settings. This high-level evidence provides the necessary scientific justification for modifying nursing practice and improving infection control.

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The nurse is evaluating the arterial blood gas and vital signs of a client admitted with abdominal pain of unknown etiology who has a nasogastric tube draining green bile.

Which action should the nurse take first?