Free Trial #9
A client recovering from an exploratory laparotomy and removal of a large intestinal tumor has a nasogastric tube (NGT) in place and intravenous (IV) fluids infusion at 150 mL/hr via a pump. Which data should be reported to the health care provider?
- The IV pump keeps sounding an alarm that the high pressure has been reached.
- Intake is 1800 mL, NGT output is 550 mL, and urine output 950mL.
- Crackles are present in all lung fields.
- White blood cell count (WBC) is 9.0.
The correct answer is C. Crackles in the lungs can indicate pneumonia, atelectasis, pulmonary fibrosis, acute bronchitis, bronchiectasis, acute respiratory distress syndrome (ARDS), interstitial lung disease, or post thoracotomy or metastasis ablation. The healthcare provider would not be notified for malfunctioning equipment. The client’s intake and output is not unusual. The WBC is within normal limits.
NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.