When assessing a client with a nasogastric tube, a nurse finds ...

[tnt_battle]

When assessing a client with a nasogastric tube, a nurse finds the client is coughing, dyspneic, and wheezing. The nurse should first:
 
  A. Suction the client
  B. Aspirate GI contents
  C. Consult with the physician
  D. Position the client on his or her side

Question 2

The nurse is performing nasotracheal suctioning on a patient. The nurse should discontinue the suctioning if which of the following occurs?
 
  a. The patient coughs as the catheter is inserted.
  b. The heart rate decreases from 84 beats per minute to 60 beats per minute.
  c. An increase in pulse occurs from 74 beats per minute to 94 beats per minute.
  d. Oxygen saturation levels decrease from 97 to 94.

[duke02]

Answer to Question 1

D
D. Position the client on side to protect the airway. Suction the client nasotracheally or orotracheally to try to remove aspirated substance. Report the event immediately to the physician.
A. Suction the client nasotracheally or orotracheally to try to remove aspirated substance.
B. Aspiration of stomach contents into respiratory tract (immediate response) in the alert client, evidenced by coughing, dyspnea, cyanosis, or decreases in oxygen saturation values during the procedure is what caused the coughing and dyspnea.
C. Consult physician regarding need for chest radiograph.

Answer to Question 2

B
If the patient's pulse drops by more than 20 beats per minute, suctioning should be discontinued. The patient should cough, and this is expected. If the patient's pulse increases by more than 40 beats per minute or pulse oximetry falls below 90 or 5 from baseline, suctioning should be discontinued.

[tnt_battle]

Excellent

[tuate]

Gracias!