A postoperative client with a nasogastric tube (NGT) to low-intermittent suction reports the onset of nausea. Which action should the practical nurse take first
Auscultate for bowel sounds.
Determine if the suction is working.
Administer an as needed (PRN) dose of an antiemetic.
Observe the color of the gastric drainage.
The Correct Answer is B
A. Auscultating for bowel sounds might be important, but checking the NGT suction status is a priority when a client with an NGT reports nausea to ensure proper functioning and appropriate suction level.
B. Ensuring the NGT suction is working properly addresses the immediate concern of potential gastric accumulation contributing to nausea.
C. Administering an antiemetic might provide relief, but assessing the NGT function takes priority to address the cause.
D. Observing the color of gastric drainage is essential but comes after verifying the NGT suction functioning in the context of the reported nausea.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Allowing the client to go to the bathroom independently may pose a safety risk, particularly if the labor progresses rapidly or if she experiences increased discomfort.
B. Assisting the client to the bathroom might not be advisable if she is in active labor, as her condition can change quickly, and she may need immediate access to care.
C. Offering the client a bedpan or urinal would allow for bladder emptying but may not address the urgency of her desire to ambulate.
D. Encouraging the client to hold off until she is further dilated is appropriate, as a full bladder can impede labor progression and lead to complications. This allows for monitoring and assessment of her condition, ensuring that she remains safe and that labor can continue effectively.
Correct Answer is D
Explanation
A. Checking the perineum for changes in "show" or discharge is important for monitoring labor progress, but it does not directly address the client's immediate need to empty her bladder. This action would be more relevant if there were signs of labor progression or complications.
B. Reviewing the fetal heart rate pattern is crucial for assessing fetal well-being, but it does not resolve the client's discomfort from a full bladder. While important, it does not address the specific request made by the client.
C. Obtain a straight catheter kit to empty her bladder is unnecessary since the client can ambulate and has expressed the desire to void. Catheterization is typically reserved for clients unable to void independently or when the bladder is distended and interfering with labor progression.
D. Assist the client up to the bathroom is the correct action. Allowing the client to empty her bladder helps facilitate labor progression, as a full bladder can impede fetal descent. Since the vaginal exam is unchanged and the client is stable, ambulation to the bathroom is safe and appropriate. Additionally, this action supports the client’s autonomy and comfort during labor.
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