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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Sleeping on the left side does not directly help manage GERD. While it might help with digestion due to the positioning of the stomach, it is not a primary recommendation for GERD management.
Choice B rationale
Drinking milk is not a recommended way to soothe the stomach for a GERD patient. While milk might provide temporary relief from acid reflux, it could potentially stimulate the stomach to produce more acid, which can exacerbate GERD symptoms.
Choice C rationale
Waiting to go to bed for 1 hour after eating can help manage GERD. However, it is generally recommended to wait 2-3 hours after eating before lying down. This allows time for the stomach to empty and reduces the chance of stomach acid backing up into the esophagus.
Choice D rationale
Eating four to six small meals each day is a recommended way to manage GERD. Smaller meals are easier on the stomach, as they require less acid for digestion. This can help reduce the symptoms of GERD12.
Correct Answer is A
Explanation
Choice A rationale
The task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.
Choice B rationale
Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.
Choice C rationale
Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.
Choice D rationale
Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.
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