A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting an NG tube into the client, which of the following findings should the nurse anticipate?

Frothy pink drainage

Greenish-yellow drainage

Dark amber drainage

Coffee-ground drainage

Answer and Explanation

The Correct Answer is D

A. Frothy pink drainage is more characteristic of recent or active bleeding rather than an upper gastrointestinal bleed.
B. Greenish-yellow drainage typically indicates bile or gastric secretions rather than blood.
C. Dark amber drainage might suggest older, degraded blood but is less specific to an active upper GI bleed.
D. Coffee-ground drainage is indicative of older, partially digested blood and is expected in cases of upper gastrointestinal bleeding due to the breakdown of blood in the stomach.

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Correct Answer is A

Explanation

A. Performing neurovascular checks of the extremities is critical to detect signs of complications such as impaired circulation or nerve damage, which can occur after orthopedic surgery. This assessment is essential for early identification of potential issues.

B. While performing exercises of the ankle and toes is important for preventing complications like deep vein thrombosis, it is secondary to ensuring neurovascular integrity.

C. Instructing the client on the use of crutches is necessary for mobility and safety, but it follows the priority of monitoring for neurovascular complications.

D. Medicating the client for pain is important for comfort, but addressing potential neurovascular issues is a higher priority in the immediate postoperative period to prevent serious complications.

A. Platelets 150,000/mm³ B. Positive Western blot test C. CD4-T-cell count 180 cells/mm³ D. WBC 5,000/mm³

Correct Answer is C

Explanation

A. A platelet count of 150,000/mm³ is within the lower end of the normal range and might be monitored but is not the highest priority for intervention in the context of HIV.

B. A positive Western blot test confirms HIV infection but does not provide information on the current immune status or disease progression.

C. A CD4-T-cell count of 180 cells/mm³ indicates significant immunosuppression and is critical as it reflects the progression of HIV and the risk of opportunistic infections. This value is a priority because it directly affects the client’s immune status and potential treatment strategies.

D. A WBC count of 5,000/mm³ is within the normal range and is less critical compared to the CD4-T-cell count, which provides more specific information regarding the client’s HIV status and risk for opportunistic infections.

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A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting an NG tube into the client, which of the following findings should the nurse anticipate?

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