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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason
Act as a spokesperson to provide information to the media in inappropriate. During a disaster, the nurse manager or designated hospital spokesperson usually handles communication with the media. The unit nurse's primary focus is on patient care and ensuring the safety and well-being of the clients on their unit.
Choice B reason
Recommending to the provider a list of clients for early discharge is the action that should be taken by the nurse. During a disaster, the responsibility of the unit nurse includes recommending to the healthcare provider a list of clients who may be considered for early discharge. This decision is based on the nurse's assessment of the clients' conditions and the need to create additional capacity for incoming patients who require urgent medical attention.
Choice C reason:
Determining the need for additional providers is inappropriate. The determination of the need for additional providers during a disaster is usually made at a higher level, such as by the nursing supervisor, nurse manager, or hospital administration. The unit nurse may collaborate with the nursing leadership to assess staffing needs and provide input, but the final decision is typically made at a higher level.
Choice D reason
Deciding which clients should be transported for a higher level of care is not the responsibility of the nurse. Decisions about transferring clients for a higher level of care during a disaster are usually made collaboratively among the healthcare team, including the healthcare providers and nursing leadership. The unit nurse may provide valuable input about the clients' conditions, but the decision is not solely the responsibility of the unit nurse.
Correct Answer is D
Explanation
Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.
Choice A, acrocyanosis, is wrong because it is a normal finding in newborns.
Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.
Choice B, bradycardia, is wrong because it is not a typical sign of withdrawal.
Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.
Choice C, bulging fontanels, is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.
Normal ranges for newborn vital signs are as follows:
- Heart rate: 120 to 160 beats per minute
- Respiratory rate: 30 to 60 breaths per minute
- Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
- Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic
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