A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?
Instill 50 mL of normal saline solution into the tube and clamp the tube for one hour.
Turn the suction off while allowing the client to rinse his mouth with cool water.
Provide oral sponge toothettes so the client can cleanse and moisten his mouth.
Teach the client that the oral mucosa must remain dry to prevent aspiration.
The Correct Answer is C
Choice A Reason: This is incorrect because instilling normal saline solution into the nasogastric tube can cause fluid overload, electrolyte imbalance, or aspiration. Clamping the tube for one hour can also increase the risk of aspiration and gastric distension.
Choice B Reason: This is incorrect because turning the suction off can cause gastric distension and discomfort. Rinsing the mouth with cool water can also increase the risk of aspiration if the client swallows some of the water.
Choice C Reason: This is correct because oral sponge toothettes are soft and gentle on the oral mucosa and can help moisten and cleanse the mouth without causing irritation or aspiration.
Choice D Reason: This is incorrect because teaching the client that the oral mucosa must remain dry is false and can lead to further dryness, cracking, bleeding, and infection. The oral mucosa should be kept moist and clean to prevent these complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because hematocrit is a measure of the percentage of red blood cells in the blood, which can indicate anemia or polycythemia, but not infection.
Choice B Reason: This is correct because neutrophil count is a measure of the number of neutrophils, which are white blood cells that fight infection and inflammation. A high neutrophil count can indicate a bacterial infection, such as in the wound.
Choice C Reason: This is incorrect because serum potassium and sodium levels are measures of the electrolyte balance in the blood, which can indicate dehydration, fluid overload, or kidney dysfunction, but not infection.
Choice D Reason: This is incorrect because blood pH level is a measure of the acidity or alkalinity of the blood, which can indicate acidosis or alkalosis, but not infection.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because abdominal girth can indicate the presence of fecal impaction, but it does not reflect the client's hemodynamic status or potential complications of the procedure.
Choice B Reason: This is incorrect because bowel sounds can indicate the level of bowel motility, but they do not provide information about the client's cardiovascular or respiratory function.
Choice C Reason: This is correct because vital signs can indicate the client's baseline condition and any changes during or after the procedure. Digital removal of a fecal impaction can stimulate the vagus nerve and cause bradycardia, hypotension, or cardiac arrest.
Choice D Reason: This is incorrect because breath sounds can indicate the client's respiratory status, but they are not directly affected by the procedure. However, breath sounds should be monitored for signs of aspiration if the client receives sedation or analgesia.
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