Nokea
The nurse is sending an arterial blood gas (ABG) specimen to the laboratory for analysis. What information should the nurse include on the laboratory requisition? Select all that apply.
- A. Ventilator settings
- B. A list of client allergies
- C. The client's temperature
- D. The date and time the specimen was drawn
- E. Any supplemental oxygen the client is receiving
- F. Extremity from which the specimen was obtained
Correct Answer: A,C,D,E
Rationale: An ABG requisition usually contains information about the date and time the specimen was drawn, the client's temperature, whether the specimen was drawn on room air or using supplemental oxygen, and the ventilator settings if the client is on a mechanical ventilator. The client's allergies and the extremity from which the specimen was drawn do not have a direct bearing on the laboratory results.
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The nurse is preparing to initiate a bolus enteral feedings via nasogastric (NG) tube to a client. Which action represents safe practice by the nurse?
- A. Checking the volume of the residual after administering the bolus feeding
- B. Aspirating gastric contents before initiating the feeding to ensure that pH is greater than 9
- C. Elevating the head of the bed to 25 degrees and maintaining that position for 30 minutes after feeding
- D. Verifying correct nasogastric tube position with aspiration and administration of air bolus with auscultation
Correct Answer: D
Rationale: After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end, injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen, and aspirating the secretions and checking to see if the pH is less than 3.5 (safest method). Residual should be assessed before administration of the next feeding. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation.
The nurse in an ambulatory care clinic takes a client's blood pressure (BP) in the left arm; it is 200/118 mm Hg. Which action should the nurse implement next?
- A. Notify the primary health care provider.
- B. Inquire about the presence of kidney disorders.
- C. Check the client's blood pressure in the right arm.
- D. Recheck the pressure in the same arm within 30 seconds.
Correct Answer: C
Rationale: When a high BP reading is noted, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm but would wait at least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The nurse would notify the primary health care provider because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.
An emergency department nurse prepares to plan care for a child diagnosed with acetaminophen overdose. The nurse reviews the primary health care provider's prescriptions and prepares to administer which medication?
- A. Succimer
- B. Vitamin K
- C. Acetylcysteine
- D. Protamine sulfate
Correct Answer: C
Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It is administered orally or via nasogastric tube in a diluted form with water, juice, or soda. It can also be administered intravenously (undiluted). Protamine sulfate is the antidote for heparin. Succimer is used in the treatment of lead poisoning. Vitamin K is the antidote for warfarin.
A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? Select all that apply.
- A. Thyroxine (T4)
- B. Prolactin (PRL)
- C. Triiodothyronine (T3)
- D. Growth hormone (GH)
- E. Luteinizing hormone (LH)
- F. Adrenocorticotropic hormone (ACTH)
Correct Answer: A,C
Rationale: Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.
The nurse is preparing to care for a client postureterolithotomy who has a ureteral catheter in place. The nurse should plan to implement which action in the management of this catheter when the client arrives from the recovery room?
- A. Clamp the catheter.
- B. Place tension on the catheter.
- C. Check the drainage from the catheter.
- D. Irrigate the catheter using 10 mL sterile normal saline.
Correct Answer: C
Rationale: Drainage from the ureteral catheter should be checked when the client returns from the recovery room and at least every 1 to 2 hours thereafter. The catheter drains urine from the renal pelvis, which has a capacity of 3 to 5 mL. If the volume of urine or fluid in the renal pelvis increases, tissue damage to the pelvis will result from pressure. Therefore, the ureteral tube is never clamped. Additionally, irrigation is not performed unless there is a specific primary health care provider's prescription to do so.