A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?
Connect the nasogastric tube to high continuous suction.
Clamp the nasogastric tube and contact the healthcare provider.
Connect the nasogastric tube to suction as prescribed.
Immediately remove and then reinsert the nasogastric tube.
The Correct Answer is B
A. Connecting the nasogastric tube to high continuous suction without further assessment or intervention is not appropriate and could exacerbate the situation.
B. Clamping the nasogastric tube and contacting the healthcare provider is the correct action. "Coffee ground" drainage can indicate the presence of blood in the stomach, which may require further evaluation and intervention by the healthcare provider.
C. Connecting the nasogastric tube to suction as prescribed without addressing the presence of "coffee ground" drainage is not appropriate. It's important to assess the significance of this finding before proceeding with suctioning.
D. Immediately removing and then reinserting the nasogastric tube may not be necessary and could increase the risk of trauma or complications. It's important to assess the situation further and involve the healthcare provider in decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA to help prevent airway obstruction during sleep. However, applying the
positive airway pressure device is a more immediate and direct intervention to ensure adequate breathing.
B. Removing dentures or other oral appliances may be necessary for comfort and safety during sleep, but it's not directly related to managing obstructive sleep apnea in this scenario.
C. Lifting and locking the side rails in place is a standard safety measure in healthcare settings but does not address the client's obstructive sleep apnea or ensure adequate ventilation.
D. Applying the client's positive airway pressure (PAP) device is the most important intervention before leaving the client. The PAP device helps maintain an open airway by delivering
continuous positive airway pressure, which is crucial for managing obstructive sleep apnea and preventing complications such as apnea episodes during sleep.
Correct Answer is ["2.4"]
Explanation
Convert the client's weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds.
Calculate the total number of units of heparin needed by multiplying the client's weight in kilograms by the prescribed dosage (3 units/kg).
Determine the volume of heparin to administer by dividing the total number of units needed by the concentration of the vial (100 units/mL).
The calculation:
Client's weight in kg: 175 pounds / 2.2 = 79.55 kg (rounded to the nearest tenth)
Total units of heparin needed: 79.55 kg 3 units/kg = 238.65 units
Volume of heparin to administer: 238.65 units / 100 units/mL = 2.39 mL
Therefore, the nurse should administer 2.4 mL of heparin. (rounded to the nearest tenth)
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