A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?

Prepare to initiate antibiotic therapy.

Obtain a prescription for a chest x-ray.

Position the client on their side.

Suction the client's orotracheal airway.

Answer and Explanation

The Correct Answer is C

A. Prepare to initiate antibiotic therapy: Antibiotics may be necessary if aspiration pneumonia develops, but this is not an immediate nursing action. Medication initiation requires provider evaluation and a prescription, making this a delayed intervention.

B. Obtain a prescription for a chest x-ray: A chest x-ray may be ordered to confirm aspiration, but requesting this is not the nurse’s next priority. Immediate nursing interventions to protect the airway and prevent further complications must occur first.

C. Position the client on their side: Placing the client on their side helps prevent further aspiration and promotes drainage of secretions or feeding material from the airway. This is the safest immediate response after stopping the feeding.

D. Suction the client's orotracheal airway: Suctioning is appropriate if the client has visible secretions, is coughing ineffectively, or shows respiratory distress. However, the priority immediate action is to position the client to reduce aspiration risk before suctioning if needed.

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Correct Answer is C

Explanation

A. "I can leave my contact lenses in place during surgery.": Contact lenses must be removed before general anesthesia because they can cause corneal irritation or injury. Additionally, dry eyes during anesthesia increase the risk of corneal damage if lenses are left in place.

B. "I will pull my hair back with a hair clip before applying the surgical cap.": Hair clips and pins are not permitted in the operating room because they may pose a risk of injury, interfere with surgical positioning, or be a source of contamination under the cap.

C. "I should remove nail polish from my fingers before surgery.": Removing nail polish is essential because it allows accurate monitoring of oxygen saturation with a pulse oximeter. Nail polish can block or distort light transmission, leading to inaccurate readings.

D. "I can keep my eye makeup on during surgery.": Eye makeup should not be worn because particles can enter the eye during anesthesia and cause irritation or infection. Additionally, makeup can interfere with the sterile environment of the operating room.

A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in). B. Auscultate each of the four quadrants for 5 min before determining sounds are absent. C. Percuss each of the four quadrants of the abdomen. D. Inspect each of the four quadrants for abdominal distention.

Correct Answer is B

Explanation

A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in): Palpation assesses tenderness, masses, or organ enlargement but does not evaluate peristalsis. Palpating too soon postoperatively can also cause discomfort or disrupt healing.

B. Auscultate each of the four quadrants for 5 min before determining sounds are absent: Bowel sounds indicate peristalsis, and a full 5 minutes of auscultation is required before concluding they are absent, especially after abdominal surgery where bowel activity may be reduced.

C. Percuss each of the four quadrants of the abdomen: Percussion evaluates the presence of fluid, gas, or organ borders but does not provide information about bowel motility. It is useful for assessing distention but not peristalsis.

D. Inspect each of the four quadrants for abdominal distention: Inspection identifies visible abnormalities such as distention, scars, or pulsations. While distention may suggest reduced peristalsis, visual inspection alone does not confirm bowel activity.

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A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?

Nursing Test Bank

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