Page 2609 - Saunders Comprehensive Review For NCLEX-RN

as a more constant generalized discomfort. Option 4 is the description of the physical
finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or
hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a
sign of paralytic ileus or intestinal obstruction.
Test-Taking Strategy: Focus on the subject, clinical manifestations of paralytic
ileus. Noting the word paralytic will assist in directing you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: GI Accessory organs
Priority Concepts: Elimination; Inflammation
Reference: Lewis et al. (2017), pp. 950-951.

922. Answer: 1

Rationale: For the first 12 hours after gastric surgery, the nasogastric tube
drainage may be dark brown to dark red. Later, the drainage should change to a
light yellowish-brown color. The presence of bile may cause a green tinge. The
PHCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24
hours postoperatively.
Test-Taking Strategy: Focus on the subject, the need to notify the PHCP. Recall
that bleeding is a concern in the postoperative client. This concept will direct you to
the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Upper GI Disorders
Priority Concepts: Clinical Judgment; Collaboration
Reference: Lewis et al. (2017), p. 344.

923. Answer: 1

Rationale: The client should take a deep breath, because the client’s airway will be
temporarily obstructed during tube removal. The client is then told to hold the
breath and the tube is withdrawn slowly and evenly over the course of 3 to 6
seconds (coil the tube around the hand while removing it) while the breath is held.
Bearing down could inhibit the removal of the tube. Exhaling is not possible during
removal because the airway is temporarily obstructed during removal. Breathing
normally could result in aspiration of gastric secretions during inhalation.
Test-Taking Strategy: Focus on the subject, the procedure for removal of a
nasogastric tube, and attempt to visualize the process of tube removal to direct you
to the correct option. Remember, holding the breath facilitates the process of
removal.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity

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