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A student nurse is precepting on the unit and caring for a client with a Dobbhoff nasoenteric tube. Which statement by the student nurse indicates the need for further teaching on caring for a client with this tube? Select all that apply.
- A. I should wait for X-ray confirmation before using the tube.
- B. I can confirm placement by auscultating over the epigastric area.
- C. I can mix liquid medications in with the tube feeding for administration.
- D. I will flush the tube with 20 to 30 mL of water every 4 hours during continuous tube feeding.
- E. I will observe the client for diarrhea, abdominal distention, nausea and vomiting, and tube dislodgement.
Correct Answer: B, C
Rationale: Auscultation is not a reliable method for confirming tube placement; X-ray is required. Mixing medications with feedings can cause clogs or interactions. The other statements are correct.
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A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:
- A. Prevent the development of acute respiratory failure
- B. Decrease cerebral blood flow
- C. Increase systemic tissue perfusion
- D. Prevent cerebral anoxia
Correct Answer: B
Rationale: Hyperventilation reduces PaCO2, causing vasoconstriction and decreasing cerebral blood flow to reduce intracranial pressure.
The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
Which of the following is the best indicator of the diagnosis of HIV?
- A. White blood cell count
- B. ELISA
- C. Western Blot
- D. Complete blood count
Correct Answer: C
Rationale: The Western Blot is the most specific test for confirming HIV diagnosis after a positive ELISA.
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
- A. Irrigate the nasogastric tube with distilled water.
- B. Aspirate the gastric contents with a syringe.
- C. Administer an antiemetic medicine.
- D. Insert a new nasogastric tube.
Correct Answer: B
Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glascow coma scale.
Correct Answer: A
Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.