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. Providing protective undergarments may be necessary as a temporary measure to manage urinary incontinence, but it does not address the underlying cause. It should not be the initial intervention.
B. Encouraging increased fluid intake may exacerbate urinary incontinence if the cause is related to an overactive bladder or other urinary tract issues. It's important to determine the cause before recommending changes in fluid intake.
C. Evaluating the client's response to bladder training efforts is a relevant intervention for urinary incontinence, but it assumes that bladder training is appropriate for the client's condition. Before initiating bladder training, it's essential to assess the client's condition through proper evaluation.
D. Obtaining a clean, voided urine specimen for analysis is the priority intervention. It allows for diagnostic testing to identify potential causes of urinary incontinence, such as urinary tract
infections, urinary retention, or other underlying medical conditions. Once the cause is determined, appropriate interventions can be implemented, which may include bladder training, medication, or other treatments.
Correct Answer is ["A","F"]
Explanation
A. Post-cardiac catheterization patients require careful monitoring of fluid intake to avoid fluid overload, which can stress the heart and lead to complications.
B. Monitoring vital signs every 4 hours is a standard procedure for a patient post-cardiac catheterization to ensure stability.
C. Continuous cardiopulmonary monitoring is also standard post-procedure to promptly detect any arrhythmias or other cardiopulmonary issues.
D. Admission to the pediatric floor for observation is appropriate for monitoring and ensuring the safety of the patient post-procedure.
E. Keeping the patient NPO (nothing by mouth) is standard until they are fully awake and alert post-anesthesia to prevent aspiration.
F. Point of care blood glucose: This order might be questioned as there is no indication from the history or notes that the child has a blood glucose issue. Monitoring blood glucose is not typically a standard post-cardiac catheterization order unless there is a specific concern for blood sugar levels.
G. Checking pedal pulses every 4 hours is important to ensure there is no compromise in circulation, especially after a procedure involving the heart.
H. Checking the dressing frequently is crucial to identify any signs of bleeding or infection early.
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