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A client has had a nasointestinal (NI) tube in place for 24 hours. Which assessment finding indicates that the tube is properly located in the intestine?
- A. Bowel sounds are absent.
- B. The client denies being nauseous.
- C. Aspirate from the tube has a pH of 7.
- D. The abdominal x-ray indicates that the end of the tube is above the pylorus.
Correct Answer: C
Rationale: The nasogastric (NG) or NI tube is used to decompress the intestine and correct a bowel obstruction. Nausea should subside as decompression is accomplished. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is alkaline (7 or higher). Although bowel sounds will be abnormal in the presence of obstruction, the presence or absence of bowel sounds is not associated with the location of the tube. The end of the tube should be located in the intestine (below the pylorus). Location of the tube can also be determined by radiographs.
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The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
- A. Nebulizer
- B. Ambu bag
- C. Suction equipment
- D. Incisional splinting pillow
Correct Answer: D
Rationale: The use of an incisional splint such as a 'cough pillow' can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.
After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the cause of this client's pleural effusion?
- A. Trauma
- B. Infection
- C. Liver failure
- D. Heart failure
Correct Answer: A
Rationale: Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.
A client prescribed lithium carbonate for the treatment of bipolar disorder has a medication blood level of 1.6 mEq/L (1.6 mmol/L). Which assessment question should the nurse ask to determine whether the client is experiencing signs of lithium toxicity associated with this level?
- A. Do you hear ringing in your ears?
- B. Have you noted that your vision is blurred?
- C. Have you fallen recently because you are dizzy?
- D. Have you been experiencing any nausea, vomiting, or diarrhea?
Correct Answer: D
Rationale: Normal lithium levels are between 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). One of the most common early signs of lower level lithium toxicity is gastrointestinal (GI) disturbances such as nausea, vomiting, or diarrhea. The assessment questions in options 1, 2, and 3 are related to the findings in lithium toxicity at higher levels.
A primary health care provider prescribes acetaminophen liquid 450 mg orally every 4 hours PRN for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters (mL) to administer one dose? Fill in the blank and record your answer to the nearest whole number.
Correct Answer: 14 mL
Rationale: Use the formula for calculating medication dosages. Formula: Desired × Volume / Available = mL per dose. 450 mg × 5 mL / 160 mg = 14 mL.
The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study should the nurse review for data about the client's acid-base balance?
- A. Sodium
- B. Potassium
- C. Magnesium
- D. Phosphorus
Correct Answer: B
Rationale: A client with late-stage salicylate poisoning is at risk for metabolic acidosis because acetylsalicylic acid increases the client's hydrogen ion (H+) concentration, decreases the pH, and creates a bicarbonate deficit. Hyperkalemia develops as the body attempts to compensate for the influx of H+ by moving H+ into the cell and potassium out of the cell; thus, potassium accumulates in the extracellular space. Clinical manifestations of metabolic acidosis include the clinical indicators of hyperkalemia, including hyperpnea, central nervous system depression, twitching, and seizures. Options 1, 3, and 4 are not primary concerns.