The practical nurse (PN) is providing care for a client who is NPO after a small bowel resection. The client's NG tube is connected to low intermittent suction. The client reports dizziness and tingling in digits. Which assessment finding by the PN should be reported to the healthcare provider.
Hyperactive bowel sounds on assessment.
Regular heart rate of 100 beats per minute on telemetry.
Hypoactive bowel sounds on assessment.
Heart rate of 90 beats per minute with PVCs noted on telemetry.
The Correct Answer is D
A. Hyperactive bowel sounds on assessment: Increased bowel sounds may be expected postoperatively and with NG suctioning, but they are not immediately life-threatening and do not require urgent reporting.
B. Regular heart rate of 100 beats per minute on telemetry: A heart rate of 100 bpm is at the upper limit of normal for adults and, in the absence of other symptoms, is not an urgent concern.
C. Hypoactive bowel sounds on assessment: Reduced bowel sounds are common after abdominal surgery and with NPO status, but they are not immediately critical unless associated with other signs of obstruction or deterioration.
D. Heart rate of 90 beats per minute with PVCs noted on telemetry: Premature ventricular contractions (PVCs) in the context of dizziness, tingling, and NG suctioning may indicate electrolyte imbalances, such as hypokalemia or hypomagnesemia. This finding should be reported promptly for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.0"]
Explanation
Identify the prescribed dose and the available concentration.
Prescribed dose = 5 mg
Available concentration = 10 mg per 2 mL
Calculate the volume in milliliters (mL) to administer.
Volume (mL) = (Prescribed dose (mg) / Available concentration (mg)) x Available volume (mL)
= (5 mg / 10 mg) x 2 mL
= 0.5 x 2 mL
= 1.0 mL.
Correct Answer is D
Explanation
A. Document the client's loss of memory in the record: While documentation is important, recording the symptom alone does not address the client’s immediate disorientation or provide support for orientation.
B. Encourage the client to rest during the day: Promoting rest can be helpful for overall cognitive function, but it does not directly assist the client in regaining orientation or managing confusion in the moment.
C. Notify the family of the change in the client's condition: Informing family may be appropriate if the confusion persists or worsens, but the first priority is to reorient and support the client in real time.
D. Remind the client what day of the week it is: Reorientation is the initial nursing intervention for acute confusion. Providing cues about time, place, and situation helps the client regain orientation and reduces anxiety associated with disorientation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.