A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?
The amount of drainage is gradually decreasing.
The client's abdomen becomes distended and firm.
The client reports being extremely thirsty with a sore throat.
The drainage is bright green in color with brown fecal material.
The Correct Answer is B
Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.
The nurse should report this finding to the provider and assess for signs of shock or peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The client should wash their perineal area twice a day with antimicrobial soap to prevent infection and irritation. This is especially important for clients who have an impaired immune system due to chemotherapy, as they are more susceptible to infections and complications.
Correct Answer is A
Explanation
Practice standards indicateblood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary.A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.
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