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A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?
- A. Instill 500 ml of solution through the NG tube.
- B. Insert a large-bore NG tube.
- C. Use a cold irrigation solution.
- D. Instruct the client to lie on their right side.
Correct Answer: B
Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.
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During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?
- A. Low back pain.
- B. Dyspnea.
- C. Hypotension.
- D. Thready pulse.
Correct Answer: B
Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.
A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?
- A. Administer the feeding over 30 minutes
- B. Place the child in a supine position after the feeding
- C. Change the feeding bag and tubing every 3 days
- D. Warm the formula in a warm water bath before administration
Correct Answer: B
Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.
When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?
- A. Allow the client enough time to perform rituals
- B. Give the client autonomy in scheduling activities
- C. Discourage the client from exploring irrational fears
- D. Provide negative reinforcement for ritualistic behaviors
Correct Answer: A
Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.
A client has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: Generalized petechiae and ecchymoses can indicate a potential issue with platelet function or count. Therefore, the most relevant laboratory test to evaluate this condition would be a platelet count. Platelet count helps assess the number of platelets in the blood, which are crucial for clotting and preventing bleeding. Monitoring platelet levels can provide important information about a client's bleeding risk and overall hematologic health.
When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?
- A. Arrange for an ethics committee meeting to address the family's concerns.
- B. Support the family's decision and initiate life-sustaining measures.
- C. Complete an incident report.
- D. Encourage the family to contact an attorney.
Correct Answer: A
Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.