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 ["B","C"]
Explanation
A. Urinalysis: While urinalysis can provide information about urinary tract infections, it is not directly related to monitoring the effectiveness of antibiotic treatment for a respiratory tract
infection.
B. White blood cell (WBC count: Monitoring WBC count can help assess the body's response to infection. A decrease in WBC count can indicate improvement in the infection.
C. Sputum culture and sensitivity: Monitoring sputum culture and sensitivity helps determine if the antibiotic is targeting the specific pathogen causing the respiratory tract infection and if the chosen antibiotic is effective against it.
D. Serum potassium: Monitoring serum potassium levels is important with certain antibiotics,
but it is not directly related to evaluating the effectiveness of antibiotic treatment for a respiratory tract infection.
E. Red blood cell (RBC count: RBC count is not typically monitored to evaluate the effectiveness of antibiotic treatment for a respiratory tract infection.
F. Blood urea nitrogen (BUN): BUN levels are not directly related to assessing the effectiveness of antibiotic treatment for a respiratory tract infection.
Correct Answer is A
Explanation
A. Pulling the pinnae up and back helps straighten the ear canal in adults, allowing easier administration of the ear drops and better penetration into the ear canal. This technique is appropriate for adults.
B. Administering the drops with the head held upright may be necessary for some ear drop medications, but it is not the most appropriate technique for all types of ear drops.
C. Cooling and shaking the bottle before administering the drops may be necessary for certain types of medications but is not universally recommended for all ear drop preparations.
D. Inserting the tip of the dropper into the canal of the ear is appropriate for administering ear drops, but it should be accompanied by the correct technique of pulling the pinnae up and back to straighten the ear canal in adults.
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