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. 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

A. Prepare to prevent respiratory or cardiac arrest B. Stop infusion of magnesium C. Increase IV fluids D. Obtain serum magnesium level E. Administer oxygen F. Obtain blood pressure G. Administer calcium gluconate

Correct Answer is ["A","B","D","E","G"]

Explanation

A. Prepare to prevent respiratory or cardiac arrest: The client's decreased level of consciousness and respiratory rate of 10 breaths/minute indicate a potential risk for respiratory or cardiac arrest. Immediate measures to maintain airway patency and support ventilation may be necessary.
B. Stop infusion of magnesium: The client's decreased level of consciousness and absent deep tendon reflexes (DTR) bilaterally are signs of magnesium toxicity. Stopping the infusion of magnesium sulfate is essential to prevent further complications.
C. Increasing IV fluids is not a priority in management of magnesium toxicity.
D. Obtain serum magnesium level: With signs of magnesium toxicity, obtaining a serum magnesium level is necessary to confirm the diagnosis and guide further management.
E. Administer oxygen: The client's oxygen saturation of 93% on room air indicates hypoxemia.
Administering oxygen via nasal cannula to maintain oxygen saturation greater than 96% helps prevent further respiratory compromise.
F. Obtaining blood pressure is not a priority.
G. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium toxicity.
Since the client is showing signs of magnesium toxicity (decreased level of consciousness and absent DTRs), administering calcium gluconate is necessary to counteract the effects of magnesium
H. Caesarian delivery is not part of management for magnesium toicity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","D","E","G"]

Explanation

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