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
Explanation
A. Instruct in effective techniques to cleanse the glans penis: While hygiene education may be important, the client's symptoms suggest a urinary issue that needs further assessment.
B. Palpate the client's suprapubic area for distention: These symptoms are consistent with urinary retention, and palpating the suprapubic area can help assess for bladder distention.
C. Advise the client to maintain a voiding diary for one week: While a voiding diary can provide valuable information, the client's symptoms indicate a need for immediate assessment and
intervention.
D. Obtain a urine specimen for culture and sensitivity: While obtaining a urine specimen is important, it may not directly address the immediate concern of possible urinary retention
Correct Answer is C
Explanation
A. This statement is not accurate and may alarm the family unnecessarily. Delirium is often reversible and can have various causes, including medical conditions, medications, and environmental factors. Institutionalization is not always necessary.
B. This statement jumps to conclusions and may cause unnecessary distress to the family. While dementia is a possibility, it is not appropriate to make a diagnosis without further assessment and evaluation by a healthcare provider.
C. This response acknowledges the family's concerns and suggests a possible cause for the client's symptoms. Depression can manifest as cognitive symptoms such as difficulty
concentrating and remembering, and it is often reversible with appropriate treatment and support.
D. Alzheimer's disease is a progressive neurodegenerative disorder and is not typically reversible. This statement may give false hope to the family and does not address the client's current symptoms effectively.
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