Nokea
The client has a nasogastric tube. The healthcare provider orders IV fluid replacement based on the previous hour's output plus the baseline IV fluid ordered of 125 mL/hr. From 0800 to 0900 the client's N/G tube drained 45 mL. At 0900, what rate should the nurse set for the IV pump?
Correct Answer: 170 mL/hr
Rationale: Baseline IV fluid is 125 mL/hr, plus 45 mL NG output = 125 + 45 = 170 mL/hr.
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- A. Check the client's glucose level.
- B. Administer an oral hypoglycemic.
- C. Assess the peripheral intravenous site.
- D. Monitor the client's oral food intake.
Correct Answer: A
Rationale: TPN, high in dextrose, can cause hyperglycemia, so monitoring glucose levels is essential, especially in IBD patients with potential metabolic stress. Oral hypoglycemics are inappropriate, TPN uses central lines, and oral intake is typically minimal.
Which oral medication should the nurse question before administering to the client with peptic ulcer disease?
- A. E-mycin, an antibiotic.
- B. Prilosec, a proton pump inhibitor.
- C. Flagyl, an antimicrobial agent.
- D. Tylenol, a nonnarcotic analgesic.
Correct Answer: A
Rationale: E-mycin (erythromycin) can irritate the gastric mucosa and exacerbate peptic ulcer disease, so it should be questioned. Prilosec and Flagyl treat ulcers (especially H. pylori-related), and Tylenol is safe for pain relief.
The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?
- A. The nursing care plan for postoperative day one indicates restricting fluids to 30—60 mL per hour of clear liquids.
- B. The nurse is instructing the licensed practical nurse (LPN) to remove the client’s urinary catheter 24 hours after surgery.
- C. The client is wearing a bilevel positive airway pressure (BiPAP) mask when sleeping during the day.
- D. A bottle of saline and 60-mL catheter-tip syringe are on the bedside table for nasogastric (NG) tube irrigation.
Correct Answer: D
Rationale: A. For the first 24-48 hours postoperatively, the client sips small amounts of clear liquids to avoid nausea, vomiting, and distention and stress on the suture line. B. If used, urinary catheters should be removed within 24 hours after surgery to prevent UTIs and to encourage mobility. The nurse may delegate this task to an LPN. C. The BiPAP mask is used to keep the airway open and should be worn whenever the client is sleeping. D. A bottle of saline and a large-sized syringe may indicate that the client’s NG tube has been or will be irrigated. Manipulating or irrigating an NG tube with too much solution can lead to disruption of the anastomosis in gastric surgeries. If an NG tube is present the surgeon should be consulted before irrigating the tube.
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- A. Call the HCP and suggest he or she talk with the client.
- B. Determine what about the HCP is bothering the client.
- C. Notify the nursing supervisor to arrange a new HCP to take over.
- D. Explain the client cannot request another HCP until after discharge.
Correct Answer: B
Rationale: Determining the specific issue allows the nurse to address the concern effectively, whether through communication, advocacy, or escalation. Contacting the HCP or supervisor prematurely or dismissing the client’s request is less appropriate.
The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client?
- A. Tell the client to measure the amount of stool.
- B. Recommend the client come to the clinic immediately.
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Correct Answer: C
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