A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?
Wall suction set to 60 mm Hg
Drainage fluid is greenish-yellow
Aspirate pH of 3
Abdominal rigidity
The Correct Answer is B
A. The wall suction setting does not directly indicate the functioning of the NG tube.
B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting
that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.
C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.
D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.
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Related Questions
Correct Answer is C
Explanation
A. A client with chronic obstructive pulmonary disease who needs guidance on incentive spirometry requires nursing judgment and education to ensure proper technique, so this task is best performed by a nurse.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires assessment and potential intervention by a nurse to address cardiac issues.
C. Assisting a client with toileting typically involves tasks such as transferring, positioning, and providing hygiene assistance, which can be safely delegated to an assistive personnel.
D. Providing a client who has awoken following a bronchoscopy with a drink involves assessing for the absence of nausea or vomiting and ensuring the client can swallow safely, which requires nursing judgment and should be performed by a nurse.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
A. It would not be appropriate to place the client on restraints as this would increase agitation and he is not violent.
B. The client may have a urinary tract infection (UTI) that is causing fever, hypotension, and confusion. Monitoring elimination can help assess the severity of the infection and the need for antibiotics.
C. Dimming the lights can help reduce sensory overload and agitation in the client.
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