Two hours after an IV was initiated at 200 mL/h on your elderly patient, your patient develops dyspnea, a cough, and a rapid heart rate. You suspect:

Sepsis

Anaphylaxis

Myocardial infarction

Circulatory overload

Answer and Explanation

The Correct Answer is D

Rationale:
A. Sepsis usually develops over time with signs such as fever, chills, and hypotension, not acute fluid-related symptoms.
B. Anaphylaxis presents with airway swelling, rash, hypotension, and wheezing rather than fluid overload symptoms.
C. Myocardial infarction may cause chest pain, diaphoresis, and ECG changes, not typically linked directly to IV infusion rate.
D. Circulatory overload is the most likely cause. Rapid infusion (200 mL/hr in an elderly patient) can overwhelm cardiac function, leading to dyspnea, cough, tachycardia, and signs of fluid overload.

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Correct Answer is C

Explanation

Rationale:
A. Examining the nares for patency and skin breakdown is important for safety but does not directly reduce discomfort during insertion.
B. Placing the patient in high-Fowler’s position promotes safe passage and reduces aspiration risk, but it does not specifically relieve discomfort.
C. Anesthetizing the throat (e.g., with a topical anesthetic spray or viscous lidocaine) can numb the mucosa, significantly reducing discomfort during NG tube insertion.
D. Having the patient sip water helps advance the tube once insertion has started, but it does not reduce the initial discomfort of tube passage.

A. From the tip of the nose to the xiphoid process of the sternum. B. From the earlobe to the xiphoid process of the sternum. C. From the tip of the nose to the earlobe to the xiphoid process. D. From the tip of the nose to the earlobe.

Correct Answer is C

Explanation

Rationale:
A. Measuring only from the nose to the xiphoid process omits the earlobe landmark, leading to inaccurate length.
B. Measuring from the earlobe to the xiphoid process also omits part of the required distance.
C. The correct measurement for NG tube insertion is from the tip of the nose → earlobe → xiphoid process. This ensures the tube is long enough to reach the stomach without being excessively long.
D. Measuring only to the earlobe is incomplete and far too short for gastric placement.

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Two hours after an IV was initiated at 200 mL/h on your elderly patient, your patient develops dyspnea, a cough, and a rapid heart rate. You suspect:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube?

Correct Answer is C

Explanation

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the needed length of the tube to be inserted, the nurse measures what length?

Correct Answer is C

Explanation

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