The nurse is determining a patient's gastric residual before administering an enteral feeding; the last feeding was 240 mL. The patient will be discharged on enteral feedings. It is important to include in the teaching plan that a residual of more than which amount would indicate delayed gastric emptying (based on the last feeding)?

Correct Answer: A

Rationale: A gastric residual volume of more than 60 mL (or 25% of the last feeding) suggests delayed gastric emptying, which increases the risk of aspiration. The nurse should hold the feeding and reassess if the residual exceeds this threshold. Higher residuals (B, C, D) are not acceptable indicators.

Correct Answer: A

Rationale: The correct instruction to the patient who is taking clopidogrel (Plavix) and aspirin and is preparing for orthopedic surgery is to continue taking aspirin and stop taking clopidogrel 2 weeks prior to surgery. Clopidogrel is an antiplatelet medication that irreversibly inhibits platelet activation and aggregation, which can increase the risk of bleeding during surgery. However, aspirin has a different mechanism of action and does not have as profound an effect on platelet function as clopidogrel. By continuing aspirin and stopping clopidogrel, the patient can still receive some antiplatelet protection while minimizing the bleeding risk associated with clopidogrel. It is important for the nurse to consult with the surgeon to ensure the best course of action for the patient's specific situation.

Correct Answer: A

Rationale: Albuterol is an example of a bronchodilator medication commonly used to treat respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Bronchodilators work by relaxing the muscles in the airways, which helps to open up the air passages and improve airflow to the lungs. This action can help relieve symptoms like wheezing, shortness of breath, and chest tightness. Albuterol is typically administered via inhalation to provide quick relief during an asthma attack or COPD exacerbation.

Correct Answer: B

Rationale: Theophylline overdose (empty bottle) causes cardiac arrhythmias . Toxicity leads to tachyarrhythmias, often fatal. Apnea is secondary. Pulmonary embolism lacks context. Seizures occur but aren't primary. Tetany (E) is unrelated. Arrhythmias align with theophylline's narrow therapeutic index.

Correct Answer: D

Rationale: A sudden increase in temperature in a client receiving Pentamidine IV for the treatment of Pneumocystis carinii is most likely an indication that the client has developed another infection. Pentamidine is an antiparasitic medication used to treat Pneumocystis carinii pneumonia in immunocompromised individuals such as those with HIV/AIDS. An increase in temperature could be a sign of a new or worsening infection, especially in patients who are already immunocompromised. It is important for the nurse to monitor the client closely for signs of infection and notify the healthcare provider if there are any concerning symptoms.