Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.

Which of the following actions should the nurse perform first?

Replace the NG tube.

Provide oral hygiene care.

Administer an antiemetic

Evaluate functioning of the suction device

Answer and Explanation

The Correct Answer is D

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

Prompt assessment of the suction device is crucial to determine if it's functioning properly. If the suction is inadequate, it can lead to gastric contents accumulating and potentially causing vomiting.
Assessing the suction device first allows for timely intervention if it's not working correctly, preventing further complications and discomfort for the client.

Choice A rationale:

Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B. Apply direct pressure to the puncture site.

Choice A rationale:

Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.

Choice B rationale:

Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.

Choice C rationale:

Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.

Choice D rationale:

Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.

A. Swaddle the newborn with his legs extended. B. Administer naloxone to the newborn C. Maintain eye contact with the newborn during feedings D. Minimize noise in the newborn’s environment

Correct Answer is D

Explanation

The correct answer is choice D. Minimize noise in the newborn’s environment.

This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.

Minimizing noise and other stimuli can help calm the newborn and reduce stress.

Choice A is wrong because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.

Choice B is wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.

Choice C is wrong because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing.

Correct Answer is B

Explanation

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes.

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.

Which of the following actions should the nurse perform first?