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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: "I'm sorry, but your child's medical information is none of your business." is not a good response because it is rude and disrespectful. The nurse should maintain professionalism and empathy when dealing with parents.

Choice B: "I can give you those results as soon as I get them back from the lab." is not a good response because it violates confidentiality and privacy. The nurse should not share any medical information with anyone without the client's consent.

Choice C: "The healthcare provider will share this information with you." is not a good response because it implies that the parents have a right to know their child's medical information. The nurse should not make promises or assumptions that may not be true.

Choice D: "I can only give medical information to your child because they are legally an adult." is a good response because it explains the legal status of an emancipated minor and respects their autonomy. The nurse should inform the parents that their child has the right to make their own decisions regarding their health care.

A. Irrigate the nasogastric tube with water. B. Review the advance directive document. C. Elevate the head of bed 45 degrees. D. Perform oropharyngeal suctioning.

Correct Answer is D

Explanation

The correct answer is: d. Perform oropharyngeal suctioning.

Choice A: Irrigate the nasogastric tube with water

Reason: Irrigating the nasogastric tube with water is not appropriate when a client is choking and vomiting. This action could potentially worsen the situation by introducing more fluid into the stomach, increasing the risk of aspiration.

Choice B: Review the advance directive document

Reason: Reviewing the advance directive document is not an immediate action to take when a client is choking. Advance directives provide guidance on the client’s wishes for medical treatment but do not address acute emergency interventions.

Choice C: Elevate the head of bed 45 degrees

Reason: Elevating the head of the bed to 45 degrees can help reduce the risk of aspiration by using gravity to keep stomach contents down. However, this action alone is not sufficient to address the immediate choking hazard.

Choice D: Perform oropharyngeal suctioning

Reason: Performing oropharyngeal suctioning is the correct action because it directly addresses the choking hazard by clearing the airway of vomit and other obstructions. This is a critical step to ensure the client’s airway is clear and they can breathe properly.

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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?

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