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 C

Explanation

A. The client's healthcare power of attorney is important information but may not be immediately relevant to the client's current clinical status and need for medical intervention.
B. Currently prescribed medications are important to know but should not take precedence over the client's acute change in mental status, which requires immediate attention.
C. Increasing confusion of the client is the most critical information to report first as it indicates a change in the client's condition and may require urgent evaluation and intervention by the
healthcare provider.
D. The fall at home as the reason for admission is important background information but should be provided after the current assessment of the client's condition, which includes the increasing confusion.

A. Advise the UAP to resume positioning the client on schedule. B. Assume total care of the client to monitor neurologic function. C. Encourage the UAP to provide comfort care measures only. D. Assign a practical nurse to assist the UAP in turning the client.

Correct Answer is A

Explanation

Even though the client has a "Do Not Resuscitate" (DNR) order, routine care such as turning the client to prevent complications (e.g., pressure ulcers) remains important. The nurse should ensure the UAP understands the need to continue positioning the client according to the care plan, as this is a preventive measure for comfort and overall care, not a resuscitative measure.

B. Assume total care of the client to monitor neurologic function: Assuming total care may not be necessary, but providing guidance on comfort care measures is appropriate.
C.

Comfort care measures are important, but preventing complications such as pressure ulcers by turning the client is also part of providing comfort and care. Ceasing turning the client prematurely could lead to additional complications, which is not in the best interest of the patient.

D. Assign a practical nurse to assist the UAP in turning the client: While additional assistance may be helpful, ensuring that comfort care measures are provided is the priority.

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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 C

Explanation

Correct Answer is A

Explanation

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