A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?
Connect the nasogastric tube to high continuous suction.
Clamp the nasogastric tube and contact the healthcare provider.
Connect the nasogastric tube to suction as prescribed.
Immediately remove and then reinsert the nasogastric tube.
The Correct Answer is B
A. Connecting the nasogastric tube to high continuous suction without further assessment or intervention is not appropriate and could exacerbate the situation.
B. Clamping the nasogastric tube and contacting the healthcare provider is the correct action. "Coffee ground" drainage can indicate the presence of blood in the stomach, which may require further evaluation and intervention by the healthcare provider.
C. Connecting the nasogastric tube to suction as prescribed without addressing the presence of "coffee ground" drainage is not appropriate. It's important to assess the significance of this finding before proceeding with suctioning.
D. Immediately removing and then reinserting the nasogastric tube may not be necessary and could increase the risk of trauma or complications. It's important to assess the situation further and involve the healthcare provider in decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Toxoplasmosis: While toxoplasmosis can cause symptoms similar to those described, it is not typically associated with a maculopapular rash on the face. Moreover, routine screening for toxoplasmosis is not typically performed during pregnancy unless indicated by specific risk factors.
B. Group B Streptococcus: Group B Streptococcus is primarily associated with maternal
colonization and neonatal infection, but it does not typically present with a maculopapular rash on the face in the mother.
C. Gonorrhea: Gonorrhea can cause systemic symptoms, but it is not commonly associated with a maculopapular rash on the face. Additionally, routine screening for gonorrhea during pregnancy typically focuses on genital sites rather than systemic symptoms.
D. Rubella: Rubella, or German measles, presents with a maculopapular rash on the face (often described as a "slapped cheek" appearance) along with fever, malaise, sore throat, and
lymphadenopathy. Rubella infection during pregnancy can lead to congenital rubella syndrome, which can have serious consequences for the developing fetus. Therefore, it is important to
review rubella immunity status in pregnant women presenting with these symptoms.
Correct Answer is D
Explanation
A. Holding hands below elbows when rinsing is a correct technique to prevent contamination of washed hands.
B. Lathering using a circular movement is a correct technique for thorough handwashing.
C. Washing for a total of 20 seconds is in line with the recommended duration for effective handwashing.
D. Turning the water off using bare hands can potentially recontaminate the hands. Instead, a paper towel or elbow should be used to turn off the faucet after washing hands to prevent recontamination. Therefore, this action by the UAP requires additional teaching.
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