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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Client's healthcare power of attorney: While important, this information may not be
immediately relevant to the client's current condition and the reason for contacting the healthcare provider.
B. Increasing confusion of the client: This information indicates a change in the client's status and is the most pertinent to the client's current condition, warranting immediate attention.
C. Fall at home as reason for admission: While important for background information, the reason for admission is already known, and the focus of the communication should be on the client's current status.
D. Currently prescribed medications: This information is important but may not be the priority when reporting a change in the client's condition.

A. Maintain the bed flat while sleeping. B. Continue wearing compression stockings. C. Avoid prolonged standing or sitting. D. Use a recliner for long periods of sitting. E. Cross legs at the knee but not at the ankle.

Correct Answer is ["B","C","D"]

Explanation

A. Maintaining the bed flat while sleeping is not specifically related to self-care instructions for chronic venous insufficiency caused by deep vein thrombosis. In fact, elevating the legs while sleeping may be beneficial.
B. Continuing to wear compression stockings is important for managing chronic venous insufficiency and preventing complications such as edema and venous stasis ulcers.
C. Avoiding prolonged standing or sitting helps prevent venous pooling and exacerbation of symptoms associated with chronic venous insufficiency.
D. Using a recliner for long periods of sitting can help reduce venous stasis and swelling by elevating the legs and improving venous return.
E. Crossing legs at the knee can impede blood flow and exacerbate symptoms of chronic venous insufficiency. The correct instruction would be to avoid crossing legs at both the knee and ankle.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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