A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.
Which of the following actions should the nurse perform first?
Replace the NG tube.
Provide oral hygiene care.
Administer an antiemetic
Evaluate functioning of the suction device
The Correct Answer is D
The correct answer is d. Evaluate functioning of the suction device.
Choice D rationale:
- Prompt assessment of the suction device is crucial to determine if it's functioning properly. If the suction is inadequate, it can lead to gastric contents accumulating and potentially causing vomiting.
- Assessing the suction device first allows for timely intervention if it's not working correctly, preventing further complications and discomfort for the client.
Choice A rationale:
- Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
- Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.
Choice B rationale:
- Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
- Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.
Choice C rationale:
- Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
- Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states.
Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.
Choice B is wrong because antitoxin is not used to treat Lyme disease.
Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.
Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the
bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.
Choice D is wrong because skin necrosis is not a common complication of Lyme disease.
Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.
Correct Answer is A
Explanation
- Answer and explanation.
The correct answer is choice A. Increased Hct.
Hct stands for hematocrit, which is the percentage of red blood cells (RBCs) in the blood.
A client who received 2 units of packed RBCs should have an increased Hct because they have more RBCs in their blood volume. The normal range for Hct is 38% to 50% for males and 36% to 44% for females.
Choice B is wrong because decreased Hgb means decreased hemoglobin, which is the protein that carries oxygen in the RBCs.
A client who received 2 units of packed RBCs should have an increased Hgb because they have more hemoglobin in their blood. The normal range for Hgb is 13.5 to 17.5 g/dL for males and 12 to 15.5 g/dL for females.
Choice C is wrong because increased platelets means increased thrombocytes, which are the cells that help with blood clotting.
A client who received 2 units of packed RBCs should not have an increased platelet count because they did not receive platelets in the transfusion. The normal range for platelets is 150,000 to 400,000/mm^3.
Choice D is wrong because decreased WBC count means decreased leukocytes, which are the cells that fight infection and inflammation.
A client who received 2 units of packed RBCs should not have a decreased WBC count because they did not receive WBCs in the transfusion. The normal range for WBC count is 4,500 to 11,000/mm^3.
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