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 D
Explanation
A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.
B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.
C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.
D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.
Correct Answer is D
Explanation
A. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.
B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.
C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.
D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.
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