A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider?
Greenish-yellow drainage
Report of hunger
Gastric contents are present in the air vent
Abdominal distention
The Correct Answer is C
Choice A reason: This is not the correct answer because greenish-yellow drainage is a normal color for gastric secretions and does not indicate a problem.
Choice B reason: This is not the correct answer because a report of hunger is common for a client with an NG tube and does not require intervention.
Choice C reason: This is the correct answer because gastric contents in the air vent mean that the NG tube is clogged or kinked and needs to be flushed or replaced. This is the correct answer because it indicates that the NG tube is not functioning properly and could cause aspiration or infection. The other findings are expected or normal for a client with an NG tube.
Choice D reason: This is not the correct answer because abdominal distention is a common reason for placing an NG tube and should improve with gastric decompression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Removing blankets from the client is a good action to take. Blankets can trap heat and increase the body temperature. Removing them can help the client lose heat through radiation and convection.
Choice B reason: Placing cold packs on the client’s axillae is not a good action to take. Cold packs can cause vasoconstriction and shivering, which can increase the metabolic rate and the heat production. They can also cause discomfort and skin damage.
Choice C reason: Placing a fan to blow air across the client is not a good action to take. A fan can cause evaporation of sweat and moisture, which can lower the body temperature. However, it can also cause dehydration and electrolyte imbalance, which can worsen the client’s condition.
Choice D reason: Giving the client an alcohol sponge bath is not a good action to take. Alcohol can cause vasodilation and evaporation, which can lower the body temperature. However, it can also cause skin irritation, dryness, and absorption, which can lead to toxicity and complications.
Correct Answer is B
Explanation
Choice A reason: Fidelity is not the ethical principle that the nurse is implementing. Fidelity is the duty to keep one's promises and commitments to the client. The nurse is not demonstrating fidelity by giving pain medication, unless the nurse has promised to do so.
Choice B reason: Beneficence is the ethical principle that the nurse is implementing. Beneficence is the duty to do good and prevent harm to the client. The nurse is demonstrating beneficence by giving pain medication to relieve the client's suffering and promote comfort.
Choice C reason: Autonomy is not the ethical principle that the nurse is implementing. Autonomy is the right of the client to make their own decisions and choices about their health care. The nurse is not demonstrating autonomy by giving pain medication, unless the client has consented to it.
Choice D reason: Veracity is not the ethical principle that the nurse is implementing. Veracity is the duty to tell the truth and be honest with the client. The nurse is not demonstrating veracity by giving pain medication, unless the nurse has explained the purpose, benefits, and risks of the medication.
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