Question

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A 70-year-old female has been admitted to the hospital. The client has had nausea and vomiting for the past three days. Upon admission the client is slightly confused and weak. Her vital signs are: 99 F (37.2 C), respirations 20 breaths/minute, pulse 102 beats/minute, BP 96/66 mm Hg, and her pain level is an “8”on a scale of 0-10. Breath sounds are clear bilaterally upon auscultation. Pulse oximetry is 95% on room air. Bowel sounds are absent in the right and left lower quadrants and in the left upper quadrant. Abdomen is hard and distended. When questioned as to her last bowel movement, the client responds, “I have not moved my bowels in over one week.” Mucous membranes dry; skin turgor poor.

The health care provider (HCP) orders the following:

1. IV of Lactated Ringers (LR). Infuse 1 Liter of LR over 6 hours by infusion pump now. When completed infuse LR at 100 mL/h
2. Insert indwelling urinary catheter to straight drainage
3. Obtain urine analysis (UA) and urine culture and sensitivity (C& S)
4. Insert nasogastric (NG) tube to intermittent suction
5. Diet: NPO
6. Vitals signs every 4 hours
7. Labs: CBC and electrolytes stat
8. Monitor I & O every shift

Questions:

1. The HCP ordered 1 Liter of LR to infuse over 6 hours. Calculate the flow rate you will program the infusion pump.      _____________________mL/h (round to the nearest whole number).

2. The client states she has pain to her left forearm four (4) hours after the start of the infusion. Upon inspection and palpation of her forearm, the nurse notes redness and swelling at the IV site and the forearm is warm to touch. What is the initial action the nurse should take?

3. What are the recommended nursing interventions when an IV becomes infiltrated? What are the recommended nursing interventions when phlebitis is noted?

4. A urine culture C& S is ordered. How would the nurse obtain a urine C& S from a indwelling urinary catheter?

5. To whom can the nurse delegate the task of taking the urine sample to the labatory? How should the specimen be transported?

6. After an X-ray has confirmed placement of the NG tube, how would the nurse check for placement prior to the administration of medication(s) and/or feeding(s) through the NG tube?

7. The nurse is checking placement of the NG tube, what would a gastric pH of 4 or lower indicate? What would a pH of 6 or higher indicate?

8. Name two complications that can occur with an NG tube? List nursing actions to prevent these complications.

9. The client asks the nurse if she could have a glass of water because she is extremely thirsty. What is the best response for the nurse to make?

10. The client’s lab results have returned. What findings (urine and serum) would indicate dehydration?

11. What would be a priority nursing diagnosis for this client? List one short-term goal. List three interventions for your priority nursing diagnosis.

Answer 1

The HCP ordered 1 Liter of LR to infuse over 6 hours. Calculate the flow rate you will program the infusion pump. _____________________mL/h (round to the nearest whole number).

Answer is 166ml/hour

1L in 6hr

XML in 1hr

1L is 1000ml, so XML =1000/6=166.6ml/hr

The client states she has pain to her left forearm four (4) hours after the start of the infusion. Upon inspection and palpation of her forearm, the nurse notes redness and swelling at the IV site and the forearm is warm to touch. What is the initial action the nurse should take?

-remove the IV line

-apply pressure

-apply cold compressions

-apply antithrombotic ointment

What are the recommended nursing interventions when an IV becomes infiltrated?

-stop iv line

- give analgesics

-reassurance

-if allergic reaction occurs give antihistamines

What are the recommended nursing interventions when phlebitis is noted?

-moist heat as rerecommended

-analgesics

-elevate limb

-if recommended give anticoagulant

A urine culture C& S is ordered. How would the nurse obtain a urine C& S from a indwelling urinary catheter?

-Specimens are collected through an existing foley catheter

-Specimens may be collected directly from a foley into an evacuated tube or transferred from a syringe into a tube in proper aseptic manner.

To whom can the nurse delegate the task of taking the urine sample to the labatory?

Nursing assistant, it should be transported as soon as possible with all aseptic precaution.

How should the specimen be transported?

- transported in a leak proof , tightly sealed,

Leak proof containers

After an X-ray has confirmed placement of the NG tube, how would the nurse check for placement prior to the administration of medication(s) and/or feeding(s) through the NG tube?

- before feeding we have to aspirate and see, if gastric content is coming then it is assured it is in stomach

The nurse is checking placement of the NG tube, what would a gastric pH of 4 or lower indicate?

- it indicates it is gastric content

What would a pH of 6 or higher indicate?

-it is alkaline, aspirate from lung

Theoerotically gastric ph can be altered by medication, hyperventilation, lactic acid accumulation

Name two complications that can occur with an NG tube? List nursing actions to prevent these complications.

Complications :-aspirations

-perforation

-dislodgement

-refeeding syndrome

Preventive measures :-

- bedside auscultation to confirm tube position

- bubble in a cup of water

- secure the tube once inserted

The client asks the nurse if she could have a glass of water because she is extremely thirsty. What is the best response for the nurse to make?

-can wet the lips with sips of water

- make her understand she needs to be fed through NG tube, after symptoms get better will start feeds orally

The client’s lab results have returned. What findings (urine and serum) would indicate dehydration?

- protein in urine

-raised haematocrit

What would be a priority nursing diagnosis for this client?

-dehydration

-confusion

-hyperthermia

-abdominal distension

List one short-term goal.

- adequate hydration

List three interventions for your priority nursing diagnosis.

-proper iv fluids

-urine output monitoring

-monitor BP and temper