A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?
Check to see if the suction equipment is working
Remove and reinsert the NG tube
Request a prescription for a medication to ease the client's anxiety
irrigate the NG tube with 100 mL of sterile water.
The Correct Answer is A
A. Check to see if the suction equipment is working: According to the nursing process, the first step is assessment. The reported symptoms suggest that the NG tube may not be functioning, so checking the equipment should be done first.
B. Remove and reinsert the NG tube: This is invasive and not the first step. It should only be done if there's evidence of a problem that can't be fixed otherwise.
C. Request a prescription for a medication to ease the client's anxiety: This addresses the symptom but not the underlying cause (possible NG malfunction).
D. Irrigate the NG tube with 100 mL of sterile water: 100 mL is too much and could lead to aspiration. Also, this action comes after verifying equipment function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Refusal to look at stoma or participate in care: This indicates denial or emotional distress, not readiness to learn.
B. Increase in length of care in the health care facility: This is a negative outcome, not a sign of readiness to learn.
C. Increase in need for pain medication: Increased pain may interfere with learning and does not indicate readiness.
D. Interest in learning how to empty the bag: Active interest in self-care tasks is a strong sign of readiness to learn and take part in self-management.
Correct Answer is A
Explanation
A. Coughing, choking, gagging, and drooling food: These are hallmark signs of dysphagia and possible aspiration. Difficulty swallowing can lead to aspiration of food or liquids into the airway, triggering protective reflexes like coughing and gagging.
B. Swallowing more than once after taking a bite of food: While this can be associated with difficulty swallowing, it is a subtle sign and not as clearly indicative of aspiration as choking or coughing.
C. Swallowing liquid immediately after taking a sip of a beverage: This reflects normal swallowing mechanics and does not indicate dysphagia.
D. Highly sensitive gag reflex: A strong gag reflex is actually a protective mechanism and not a sign of dysphagia. A diminished gag reflex would be more concerning.
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