A client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the
... [Show More] nasogastric tube in the last 2 hours. Which action should the nurse take first?
a. Irrigate the nasogastric tube with sterile normal saline
b. Reposition the client on her side
c. Advance the nasogastric tube 5 cm
d. Administer an intravenous antiemetic as prescribed
ANS: B
The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client’s nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D.
2. The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client’s serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?
a. Increased serum albumin level
b. Decreased serum creatinine
c. Decreased serum ammonia level
d. Increased liver function test results
ANS: C
The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.
3. A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?
a. Administer Lidocaine, 75 mg IV push
b. Perform synchronized cardioversion
c. Defibrillate the client as soon as possible
d. Administer Atropine, 0.4 mg IV push
ANS: B
With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.
4. The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse take first?
a. Recommend mental health counseling
b. Review the medication actions and interactions
c. Assess for the client’s daily activity level
d. Provide information regarding a support group
ANS: B
Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. Options A, C, and D might be implemented after the physiologic aspects of the situation have been assessed.
5. The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client’s goal of osteoporosis prevention?
a. Cross-country skiing
b. Scuba diving
c. Horseback riding
d. Kayaking
ANS: A
Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less. [Show Less]