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 D
Explanation
Choice A reason: Directing the partner to leave and return once postmortem care is complete is not respectful of the partner's feelings and wishes. The nurse should allow the partner to stay and participate in the postmortem care if they desire.
Choice B reason: Instructing the partner not to touch the client’s body is not compassionate or supportive of the partner's grief. The nurse should encourage the partner to touch, hold, or kiss the client’s body as a way of saying goodbye.
Choice C reason: Placing the client’s personal belongings in a safe location in the facility is a necessary action, but not the priority. The nurse should first ask the partner if they want to keep any of the belongings or give them to the nurse for safekeeping.
Choice D reason: Asking the partner about any rituals they would like to be performed is the most appropriate action. The nurse should respect and facilitate the partner's cultural, religious, or personal preferences for postmortem care.
Correct Answer is D
Explanation
Choice A reason: "I will keep your personal information private." is not a statement of advocacy, but a statement of confidentiality. Confidentiality is the ethical and legal obligation of the nurse to protect the client's privacy and information. Advocacy is the act of supporting and protecting the client's rights and interests.
Choice B reason: "I will do my best to fulfill my promises to you." is not a statement of advocacy, but a statement of accountability. Accountability is the responsibility of the nurse to answer for their actions and outcomes. Advocacy is the act of supporting and protecting the client's rights and interests.
Choice C reason: "I will speak with your provider on your behalf." is not a statement of advocacy, but a statement of communication. Communication is the exchange of information and ideas between the nurse and the client, the provider, and other members of the health care team. Advocacy is the act of supporting and protecting the client's rights and interests.
Choice D reason: "I will let you make decisions about your health care." is a statement of advocacy. Advocacy is the act of supporting and protecting the client's rights and interests, such as the right to informed consent, self-determination, and autonomy. The nurse should respect the client's choices and preferences, and assist them in making informed decisions.
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