What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture?
Notify the health care provider
Irrigate the tube with water
Check the tube placement
Assess the pH of the contents
The Correct Answer is A
Rationale:
A. Coffee-ground aspirate indicates the presence of partially digested blood, often from gastrointestinal bleeding. The nurse’s priority is to notify the health care provider immediately for further evaluation and intervention.
B. Irrigating the tube with water could worsen bleeding or obscure diagnostic evaluation.
C. Checking tube placement is not the priority when abnormal aspirate indicating bleeding is found.
D. Assessing pH helps confirm placement but does not address the critical finding of possible GI bleeding.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. The unit manager is not responsible for interpreting prescriber orders and should not be relied upon for this task.
B. The unit secretary is not qualified to interpret medical orders.
C. The nurse must call the prescriber directly to clarify any unclear or illegible order. Administering medication without a clear order is unsafe and could result in serious errors.
D. Pharmacists can clarify medication details but cannot interpret illegible handwriting; the prescriber must provide clarification.
Correct Answer is D
Explanation
Rationale:
A. Sepsis usually develops over time with signs such as fever, chills, and hypotension, not acute fluid-related symptoms.
B. Anaphylaxis presents with airway swelling, rash, hypotension, and wheezing rather than fluid overload symptoms.
C. Myocardial infarction may cause chest pain, diaphoresis, and ECG changes, not typically linked directly to IV infusion rate.
D. Circulatory overload is the most likely cause. Rapid infusion (200 mL/hr in an elderly patient) can overwhelm cardiac function, leading to dyspnea, cough, tachycardia, and signs of fluid overload.
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