Question

The charge nurse instructs the PN to turn off the intermittent suction and clamp the Salem Sump NGT of a client who is going to X-ray. While transferring to a wheelchair, the client begins to vomit coffee grounds emesis, so the PN provides oral care suction using a Yankauer tip catheter. What action should the PN implement NEXT?

Answer 1

The PN should unclamp the Salem Sump NGT to allow gastric decompression and prevent further vomiting, inform the charge nurse, reassess the patient's vital signs, and monitor for signs of continued bleeding or distress.

Step-by-step explanation:

After providing oral care suction with a Yankauer tip catheter due to the client vomiting coffee grounds emesis, the practical nurse (PN) should next reassess the client's condition. Vomiting such material indicates possible gastrointestinal bleeding, and with the Salem Sump NGT clamped, there is a risk of aspiration and further complications. The PN should immediately unclamp the Salem Sump NGT to allow for decompression of the stomach and removal of any gastric contents, thereby preventing further vomiting and potential aspiration. After that, the PN should inform the charge nurse and prepare to reassess the patient's vital signs, monitoring for any signs of deterioration or continued bleeding. If the patient is in distress or their condition is worsening, the PN needs to call for emergency medical assistance and follow the facility's protocols for emergency response.