A postoperative client with a nasogastric tube (NGT) to low-intermittent suction reports the onset of nausea. Which action should the practical nurse take first
Auscultate for bowel sounds.
Determine if the suction is working.
Administer an as needed (PRN) dose of an antiemetic.
Observe the color of the gastric drainage.
The Correct Answer is B
A. Auscultating for bowel sounds might be important, but checking the NGT suction status is a priority when a client with an NGT reports nausea to ensure proper functioning and appropriate suction level.
B. Ensuring the NGT suction is working properly addresses the immediate concern of potential gastric accumulation contributing to nausea.
C. Administering an antiemetic might provide relief, but assessing the NGT function takes priority to address the cause.
D. Observing the color of gastric drainage is essential but comes after verifying the NGT suction functioning in the context of the reported nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications.
B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion.
C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely.
D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider.
E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.
Correct Answer is D
Explanation
A. Comprehension of simple commands might be seen in older infants or toddlers but is not specifically correlated with an infant searching for a fallen toy.
B. Ability to place objects in a container typically occurs in the sensorimotor stage but is not directly related to the scenario of an infant searching for a fallen toy.
C. Visible or audible separation anxiety is more common in younger infants when separated from their caregivers and doesn't directly correlate with an infant searching for an object.
D. Exploration beyond caregiver presence is characteristic of the sensorimotor stage in Piaget's theory, where infants develop object permanence and start to explore and search for objects beyond their immediate vicinity, such as a fallen toy.
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