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 A
Explanation
Rationale for A: The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of medical information, and since the client is an adult, medical information can only be shared with the client or individuals the client designates. The nurse must follow these regulations and inform the parent appropriately.
Rationale for B: This response is inappropriate and disrespectful. While maintaining confidentiality is crucial, the language used should be sensitive and professional when discussing privacy issues with a parent.
Rationale for C: While the healthcare provider can discuss medical information, this response deflects responsibility. The nurse should clarify that medical information can only be shared with the client unless permission is granted.
Rationale for D: Offering to share lab results with the parent without the client's consent would violate HIPAA and the client's privacy rights, making this response incorrect.
Correct Answer is D
Explanation
- A) Any level of fever is not necessarily serious after vaccination. Mild fever is a common side effect and can be monitored at home unless it exceeds 101 degrees Fahrenheit or persists beyond 48 hours.
- B) Keeping the child home from daycare is not necessary unless the child develops symptoms that warrant closer observation or care, such as a high fever or behavioral changes.
- C) Aspirin should not be given to children due to the risk of Reye's syndrome, a rare but serious condition that can cause swelling in the liver and brain.
- D) Applying a cool pack to the injection site is a safe and effective way to reduce discomfort and swelling that may occur after the vaccination.
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