A nurse is caring for a patient who has an active upper gastrointestinal bleed.
After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?
Frothy pink drainage.
Coffee-ground drainage.
Dark amber drainage.
Greenish-yellow drainage.
The Correct Answer is B
Choice A rationale
Frothy pink drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as pulmonary edema where the fluid from the lungs can sometimes appear frothy and pink.
Choice B rationale
Coffee-ground drainage is a common finding in patients with an active upper gastrointestinal bleed. When blood mixes with gastric acid, it can create a substance that resembles coffee grounds. This is often seen when a nasogastric (NG) tube is inserted into the patient.
Choice C rationale
Dark amber drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as liver disease where the urine can sometimes appear dark amber.
Choice D rationale
Greenish-yellow drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as bile duct obstruction where the bile can sometimes appear greenish-yellow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Assessing the amniotic fluid is important after rupture of membranes, but it is not the immediate priority. The nurse should first ensure the safety of the mother and baby.
Choice B rationale
Walking the patient to the bathroom is not the immediate priority. After rupture of membranes, the patient should be assisted back to bed to prevent cord prolapse.
Choice C rationale
Calling and informing the healthcare provider is important, but it is not the first action. The nurse should first assist the patient back to bed and initiate fetal monitoring.
Choice D rationale
Assisting the patient back to bed and initiating fetal monitoring is the correct action. After rupture of membranes, the priority is to assess the fetal heart rate for any signs of distress, such as bradycardia, which could indicate cord prolapse.
Correct Answer is C
Explanation
Choice A rationale
Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.
Choice B rationale
Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.
Choice C rationale
Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.
Choice D rationale
Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.