![]() ![]() Test-Taking Strategy: Focus on the subject, instilling medication into the nasogastric tube, and visualize the procedure when answering this question. There is no need to remove the tube and place it in the other nostril in order to administer a feeding in fact, this is an invasive procedure and is unnecessary. The suction should be turned off before the tubing is disconnected to check for residual volume in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. A pH less than 3.5 verifies gastric placement. Rationale: By aspirating stomach contents, the residual volume can be determined and the pH checked. Reference: Ignatavicius, Workman (2016), p. Priority Concepts: Intracranial Regulation Safety Therefore, use concepts related to gravity and preventing edema and increased intracranial pressure to answer this question.Ĭontent Area: Fundamentals of Care-Safety Remember that a primary concern is the risk for increased intracranial pressure. Test-Taking Strategy: Focus on the subject, positioning following craniotomy. A reverse Trendelenburg’s position would not be helpful and may be uncomfortable for the client. A flat position or Trendelenburg’s position would increase intracranial pressure. The client should not be positioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. Rationale: Clients who have undergone crainotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. Priority Concepts: Clinical Judgment Tissue Integrity Remember that pallor, coolness, pain, numbness, and swelling are signs of infiltration, and that infection, phlebitis, and thrombosis are associated with warmth at the IV site.Ĭontent Area: Critical Care-Medications and Intravenous Therapy ![]() Test-Taking Strategy: Focus on the subject, clinical manifestations at the IV site. Formation of a red streak and purulent drainage is associated with phlebitis and infection. Erythema can be associated with infection, phlebitis, or thrombosis. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop, and if an electronic pump is being used, it will alarm. #Nclex pn practice test 2015 skinPallor, coolness, edema, pain, numbness, and blanched skin are the results of IV fluid being deposited in the subcutaneous tissue. Rationale: An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous tissue. Reference: Perry, Potter, Ostendorf (2014), pp. Priority Concepts: Clinical Judgment Safety ![]() Integrated Process: Nursing Process-ImplementationĬontent Area: Fundamental of Care-Medication/IV Calculations Review: Administration of in tr aven ous medication s Use basic principles related to dosage calculation and IV administration to answer this question. Test-Taking Strategy: Focus on the subject, intravenous infusion calculations. Using 500 mL as the reference point, the next hourly marking wouldīe at 375 mL, which is 125 mL less than 500. Rationale: If the IV is scheduled to run over 8 hours, the hourly rate is 125 mL/hour. Reference: Perry, Potter, Ostendorf (2014), p. Priority Concepts: Clinical Judgment Nutrition Integrated Process: Nursing Process-AssessmentĬontent Area: Critical Care-Parenteral Nutrition Of the purposes of PN to make the selection. ![]() Use nursing knowledge of these various conditions in the options and baseline knowledge Test-Taking Strategy: Note the strategic words, most likely, which tell the nurse that the correct options are the clients who require this type of nutritional support. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome. Examples of these conditions include those clients with burns, exacerbation of Crohn’s disease, and persistent nausea and vomiting due to chemotherapy. Adelphi nclex pass rate 2021.Rationale: PN is indicated in clients whose gastrointestinal tracts are not functional or must be rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. ![]()
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