Nokea
A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing action?
- A. Irrigate the NG tube with 30 ml of normal saline.
- B. Administer an antiemetic as prescribed.
- C. Assess the NG tube for patency and reposition if necessary.
- D. Provide sips of water and reassess the client's symptoms.
Correct Answer: C
Rationale: Assessing the NG tube for patency and repositioning it if necessary is the most appropriate action to relieve the client's nausea. Nausea in a client with a nasogastric tube can be due to the tube's malposition or blockage. Irrigating the NG tube with normal saline (Choice A) without assessing for patency or repositioning may worsen the situation. Administering an antiemetic (Choice B) can help manage symptoms but does not address the potential issue with the NG tube. Providing sips of water and reassessing symptoms (Choice D) may be contraindicated if there is a problem with the NG tube and could exacerbate the nausea.
You may also like to solve these questions
An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. What action should the nurse take?
- A. Notify the healthcare provider of the client's refusal
- B. Attempt to convince the client to take the medication
- C. Administer the medication without the client's consent
- D. Document the refusal and take no further action
Correct Answer: A
Rationale: The correct action is to notify the healthcare provider of the client's refusal. It is important for the healthcare provider to be informed so that they can decide on the next steps in the client's treatment, which may involve exploring alternative options or strategies. Attempting to convince the client to take the medication may not be effective, especially if the client is refusing. Administering the medication without the client's consent would violate the client's autonomy and rights. Simply documenting the refusal without further action may not address the client's treatment needs.
A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider?
- A. Insomnia
- B. Muscle cramping
- C. Increased appetite
- D. Anxiety
Correct Answer: B
Rationale: The correct answer is B: Muscle cramping. SIADH causes dilutional hyponatremia due to increased ADH release. Demeclocycline is used to block the action of ADH. Muscle cramping can indicate electrolyte imbalances related to hyponatremia, which should be reported to the healthcare provider. Insomnia, increased appetite, and anxiety are not typically associated with the side effects or complications of demeclocycline or SIADH.
A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Positive Chvostek's sign
- C. Increased joint pain
- D. Swelling in the joints
Correct Answer: B
Rationale: A positive Chvostek's sign indicates hypocalcemia, which requires immediate intervention as it can lead to life-threatening complications. Fever, increased joint pain, and swelling in the joints are common symptoms in clients with rheumatoid arthritis but do not require immediate intervention like addressing hypocalcemia.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value is most concerning?
- A. Serum glucose of 300 mg/dl
- B. Serum bicarbonate of 18 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Serum sodium of 135 mEq/L
Correct Answer: C
Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with DKA as it may indicate worsening hyperkalemia, requiring immediate intervention. Elevated serum potassium levels can lead to life-threatening cardiac arrhythmias. While elevated glucose and low bicarbonate are characteristic of DKA, hyperkalemia poses a higher immediate risk. Serum sodium within the normal range is not typically a primary concern in DKA.
When organizing home visits for the day, which older client should the home health nurse plan to visit first?
- A. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools.
- B. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level.
- C. A man with emphysema who smokes and is complaining of white patches in his mouth.
- D. A frail woman with heart failure who reported a 2-pound weight gain in the last week.
Correct Answer: A
Rationale: The correct answer is A. Dark, tarry stools may indicate gastrointestinal bleeding, a potentially life-threatening condition that requires immediate attention. Visiting this client first is crucial for prompt assessment and intervention. Choices B, C, and D do not present immediate life-threatening conditions that require urgent attention compared to the potential emergency indicated by dark, tarry stools.