A nurse has assessed the residual amount before beginning a nasogastric tube feeding and has found 100 mL. What will the nurse do next?

Correct Answer: A

Rationale: The correct answer is A) Nothing; this amount is within normal limits. In this scenario, the nurse has assessed the residual amount before initiating a nasogastric tube feeding and found it to be 100 mL. A residual amount of 100 mL is generally considered within acceptable limits for proceeding with feeding, as the typical threshold for concern is often set at <200 mL. Therefore, the nurse can continue with the feeding without any interventions. Option B) Report the finding to the physician is incorrect because, as previously mentioned, 100 mL is a common and acceptable residual amount for nasogastric tube feedings. There is no need to escalate this information to the physician. Option C) Omit the feeding and document the reason is incorrect because there is no indication to withhold the feeding based on the 100 mL residual amount. Omitting the feeding in this situation would be unnecessary and potentially harmful to the patient's nutritional status. Option D) Rinse the tube and repeat the assessment is incorrect because there is no need to repeat the assessment or rinse the tube based on the 100 mL residual amount. The nurse can confidently proceed with the feeding as planned. In an educational context, understanding the significance of residual amounts in nasogastric tube feedings is crucial for nurses caring for patients who require enteral nutrition. This knowledge ensures safe and effective delivery of nutrition while preventing complications such as aspiration. Nurses must be able to interpret residual amounts within the appropriate clinical context to make informed decisions regarding feeding regimens.

Correct Answer: D

Rationale: In the context of a patient with hyponatremia, the correct physical assessment to make is to palpate the skin of the sternum (Option D). This is because hyponatremia, which is a low sodium level in the blood, can lead to fluid retention and subsequent edema. Palpating the skin of the sternum allows the nurse to assess for signs of fluid overload such as pitting edema or skin turgor changes. Option A, observing skin color and texture, is not the most appropriate assessment in this scenario because changes in skin color and texture are more indicative of vascular or perfusion issues, rather than specifically related to hyponatremia. Option B, auscultating bowel sounds, is not directly related to assessing for hyponatremia. Bowel sounds are typically assessed in gastrointestinal or abdominal conditions, not in cases of electrolyte imbalances like hyponatremia. Option C, percussing lung density, is also not relevant to assessing hyponatremia. Lung density percussion is used to assess for conditions like pneumonia or pleural effusion, not for electrolyte imbalances. In an educational context, it is important for healthcare professionals to understand the specific physical assessments relevant to different conditions. Understanding the rationale behind each assessment helps in providing comprehensive care to patients and in identifying potential complications or changes in their condition. Palpating for edema in a patient with hyponatremia is crucial for monitoring their fluid status and ensuring appropriate interventions are implemented.

Correct Answer: B

Rationale: In this scenario, the appropriate nursing diagnosis for a patient taking a diuretic that increases urinary output is "Risk for Deficient Fluid Volume." This nursing diagnosis is correct because diuretics enhance the excretion of water and electrolytes through the kidneys, which can lead to dehydration and imbalanced fluid levels in the body. Option A, "Impaired Skin Integrity," is incorrect because it is not directly related to the increased urinary output caused by the diuretic. Skin integrity issues are more commonly associated with pressure ulcers, moisture, or friction. Option C, "Impaired Urinary Elimination," is not the most appropriate choice as the patient is actually experiencing an increase in urinary output rather than impairment in elimination. Option D, "Urinary Retention," is also an incorrect choice because urinary retention refers to the inability to empty the bladder, which is opposite to the situation described in the question. Educationally, it is essential for nurses to understand the effects of diuretics on fluid balance and the potential risks associated with increased urinary output. By correctly identifying the nursing diagnosis of "Risk for Deficient Fluid Volume," nurses can implement appropriate interventions to prevent dehydration and maintain adequate fluid balance in patients taking diuretics. This knowledge is crucial in providing safe and effective care for patients receiving diuretic therapy.

Correct Answer: D

Rationale: In the context of a patient with fluid restriction, maintaining good oral hygiene is crucial to alleviate dry mouth, a common issue that arises due to decreased fluid intake. Proper oral hygiene, such as regular mouth rinsing, brushing, and hydration of the oral mucosa, can help prevent oral discomfort and promote overall oral health. It also helps in removing food debris and bacteria that can lead to oral infections. Choosing the other options reveals why they are incorrect in this scenario: A) Back rubs may offer comfort, but they do not directly address the issue of dry mouth caused by fluid restriction. B) Chewing gum is not recommended for a patient on fluid restriction as it can stimulate saliva production, potentially increasing the need for fluids. C) Hair care, while important for patient comfort, does not directly address the physiological effects of fluid restriction on oral health. Educationally, it is important for nurses to understand the rationale behind implementing specific comfort measures for patients with fluid restrictions. By explaining the direct impact of oral hygiene on alleviating dry mouth, nurses can provide holistic care that addresses both the patient's comfort and physiological needs. This knowledge equips nurses with the skills to tailor care plans to meet individual patient needs effectively.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) The left arm should not be used. The reason for this is that when a woman has had her left breast removed for cancer and also underwent an axillary node dissection on the left side during surgery, it increases the risk of lymphedema and infection in that arm. Lymphedema is a condition that results from a blockage in the lymphatic system, leading to swelling and an increased risk of infection. Using the left arm for intravenous line placement in this situation can further exacerbate the risk of lymphedema and infection. Therefore, to minimize the potential complications and ensure patient safety, healthcare providers should avoid using the left arm for procedures like intravenous line insertion. Regarding the other options: - A) Either arm may be used: This is incorrect because using the left arm, in this case, poses a higher risk due to the lymph node dissection and potential complications. - B) Neither arm should be used: This is overly restrictive and not necessary. The right arm can still be used safely for intravenous line placement. - D) The right arm should not be used: This is incorrect as the right arm is not affected by the breast removal or lymph node dissection on the left side. Educationally, understanding the implications of surgical procedures on patient care is crucial for healthcare professionals. It highlights the importance of considering a patient's medical history and past surgeries when making decisions about procedures to prevent complications and ensure the best possible outcomes for the patient.