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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Vancomycin is not typically associated with hepatotoxicity.

B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.

C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.

D. Hypertension is not a common adverse reaction associated with vancomycin therapy.

A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit

Correct Answer is C

Explanation

A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.

B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.

C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.

D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.

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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?

Nursing Test Bank

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