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 D
A. A wall suction setting of 60 mm Hg is within the expected range for low intermittent suction. This indicates the NG tube is likely functioning appropriately in terms of suction pressure.
B. Greenish-yellow drainage is an expected finding and reflects bile-stained gastric contents. This suggests the NG tube is effectively removing gastric secretions.
C. An aspirate pH of 3 is acidic and consistent with gastric placement of the NG tube. This finding supports proper tube positioning and function.
D. Abdominal rigidity may indicate that gastric contents are not being adequately decompressed, suggesting the NG tube is obstructed or not functioning properly. This is an abnormal and concerning finding requiring immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Visitors are not completely prohibited, but their time should be limited and precautions followed, especially for children and pregnant individuals. Therefore, banning all visitors for 24 hours is unnecessary and overly restrictive.
B. Maintaining a distance of at least 3 feet from the radiation source helps reduce exposure, following the principle of distance in radiation safety. This is an appropriate and effective protective measure for the nurse.
C. Bed rest is typically required to prevent displacement of the sealed radiation device, but it is not specifically prescribed for a fixed duration like 72 hours. The duration depends on the treatment plan, so this statement is too rigid and not universally correct.
D. Dosimeter badges are worn by healthcare workers to measure occupational exposure, not by clients receiving radiation therapy. Therefore, this action is inappropriate for the client.
Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}
Explanation
A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here
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