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.

Answer and Explanation

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.

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Correct Answer is ["A","F"]

Explanation

A. Post-cardiac catheterization patients require careful monitoring of fluid intake to avoid fluid overload, which can stress the heart and lead to complications.
B. Monitoring vital signs every 4 hours is a standard procedure for a patient post-cardiac catheterization to ensure stability.
C. Continuous cardiopulmonary monitoring is also standard post-procedure to promptly detect any arrhythmias or other cardiopulmonary issues.
D. Admission to the pediatric floor for observation is appropriate for monitoring and ensuring the safety of the patient post-procedure.
E. Keeping the patient NPO (nothing by mouth) is standard until they are fully awake and alert post-anesthesia to prevent aspiration.
F. Point of care blood glucose: This order might be questioned as there is no indication from the history or notes that the child has a blood glucose issue. Monitoring blood glucose is not typically a standard post-cardiac catheterization order unless there is a specific concern for blood sugar levels.
G. Checking pedal pulses every 4 hours is important to ensure there is no compromise in circulation, especially after a procedure involving the heart.
H. Checking the dressing frequently is crucial to identify any signs of bleeding or infection early.

A. Deep vein thrombosis. B. Fat emboli. C. Pulmonary embolism. D. Infection.

Correct Answer is A

Explanation

A. Redness and swelling of the calf are classic signs of deep vein thrombosis (DVT), especially in an older adult who is immobile. DVT is a common complication in hospitalized patients, particularly those who are immobile or have other risk factors such as dehydration.
B. Fat emboli typically present with symptoms such as dyspnea, tachypnea, and petechial rash, rather than localized redness and swelling of the calf.
C. Pulmonary embolism typically presents with symptoms such as chest pain, dyspnea, tachypnea, and hemoptysis, rather than localized redness and swelling of the calf.
D. While infection can cause localized redness and swelling, the presence of dehydration and immobility increases the likelihood of a thrombotic event such as deep vein thrombosis. It is important to consider DVT as a potential cause of these findings and initiate appropriate diagnostic and preventive measures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Correct Answer is ["A","F"]

Explanation

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

Correct Answer is A

Explanation

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