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 D
Explanation
A. Increase the oxygen delivery by 10%: While hypoxemia is present, simply increasing oxygen may be insufficient for a client who is difficult to arouse and in severe respiratory distress. Immediate advanced airway intervention is a higher priority.
B. Administer PRN nebulizer treatment: Bronchodilators can improve airway obstruction but will not rapidly correct profound hypoxemia or altered mental status in a critically decompensating client. This intervention alone is not adequate.
C. Complete neurological assessment: Assessing neurological status is important, but the client’s low oxygen saturation and decreased responsiveness indicate a life-threatening situation that requires immediate intervention before completing a full assessment.
D. Prepare for rapid sequence intubation: The client exhibits severe hypoxemia, high respiratory rate, and decreased level of consciousness—signs of impending respiratory failure. Rapid sequence intubation ensures airway protection and adequate ventilation, which is the priority action to prevent respiratory arrest.
Correct Answer is A
Explanation
A. "I am not comfortable doing that; Is there something else I can do to help you?": The PN should refuse to administer an unlabeled medication because it violates safety standards and legal regulations. Offering to assist in another way demonstrates professionalism while maintaining patient safety.
B. "Teamwork is the best approach. I will be glad to help you get caught up.": Agreeing to help without addressing the unlabeled syringe does not ensure safety and could place both the PN and the patient at risk.
C. "You should know that I cannot administer the medication in this syringe.": While accurate, this statement is abrupt and does not offer an alternative solution or maintain a collaborative approach with the nurse.
D. "As long as the charge nurse checks the syringe, I can give the medication.": Administering medication in an unlabeled syringe is unsafe and not allowed under any circumstances, even if a supervisor checks it. Patient safety must come first.
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