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. Share personal values to put the client at ease: Sharing personal values may not be appropriate and could potentially alienate the client or make them feel judged.
B. Get the most difficult questions over with first: Starting with difficult questions may increase the client's defensiveness and resistance to sharing information.
C. Ask questions in a vague, non-specific format: Being vague may not elicit the necessary information and could lead to misunderstandings or incomplete responses.
D. Begin with questions that are less sensitive in nature: Starting with less sensitive questions helps build rapport and trust with the client before addressing more sensitive topics like domestic violence. It allows the client to feel more comfortable and may increase the likelihood of obtaining accurate information.
Correct Answer is D
Explanation
A. Administering aspirin may be appropriate for suspected ischemic stroke; however, it should not be done without confirmation of diagnosis and evaluation by the stroke team.
B. Initiating pneumatic compression devices is not the priority in this situation. Acute assessment and management of the suspected stroke take precedence.
C. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for ongoing care but is not the priority when the client is presenting with symptoms suggestive of a stroke.
D. Notifying the stroke team to assist with acute assessment and management is the priority intervention. Time is crucial in the management of stroke, and early intervention can help minimize neurological damage and improve outcomes.
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