A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?
Wall suction set to 60 mm Hg
Drainage fluid is greenish-yellow
Aspirate pH of 3
Abdominal rigidity
The Correct Answer is D
A. A wall suction setting of 60 mm Hg is within the expected range for low intermittent suction. This indicates the NG tube is likely functioning appropriately in terms of suction pressure.
B. Greenish-yellow drainage is an expected finding and reflects bile-stained gastric contents. This suggests the NG tube is effectively removing gastric secretions.
C. An aspirate pH of 3 is acidic and consistent with gastric placement of the NG tube. This finding supports proper tube positioning and function.
D. Abdominal rigidity may indicate that gastric contents are not being adequately decompressed, suggesting the NG tube is obstructed or not functioning properly. This is an abnormal and concerning finding requiring immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Early decelerations are typically benign and occur in response to head compression during contractions. They mirror the uterine contractions and are not associated with fetal distress.
B. Fetal hypoxia is associated with variable or late decelerations, not early decelerations.
C. Abruptio placentae is a medical emergency characterized by premature separation of the placenta from the uterine wall, which can lead to late decelerations due to fetal hypoxia.
D. Postmaturity is a term used to describe a pregnancy that extends beyond 42 weeks gestation and is not directly related to fetal heart rate patterns during labor.
Correct Answer is D
Explanation
A. Administer an antitoxin: There is no specific antitoxin available for anthrax. Treatment primarily involves antibiotics and supportive care.
B. Quarantine the client: Quarantine may not be necessary unless the client is confirmed to have an active infection or poses a risk of spreading the disease to others.
C. Monitor the client for a productive cough: While respiratory symptoms can occur in inhalation anthrax, monitoring for a productive cough alone may not be sufficient for management.
D. Begin prophylactic treatment with ciprofloxacin: Prophylactic antibiotic treatment with ciprofloxacin or doxycycline is recommended following exposure to anthrax to prevent the development of the disease.
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