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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Discard the client's last void of the collection time period: The last void must be saved, as it is part of the 24-hr collection.

B. Include toilet paper with the collected urine: Toilet paper must not be included; it contaminates the specimen.

C. Save the first void at the start of the collection time period: The first void is discarded to start the timing and ensure that only the urine produced during the 24 hours is collected.

D. The nurse should discard the first void to obtain an accurate specimen: This is the correct protocol for accurate timing and collection.

A. Assist the client to the left Sims' position. B. Put on sterile gloves. C. Hang the enema container 61 cm (24 in) above the anus D. Insert the tubing about 15 cm (6 in) into the anus.

Correct Answer is A

Explanation

A. Assist the client to the left Sims' position: This position uses gravity to promote flow into the rectum and colon and allows the enema to follow the natural direction of the colon.

B. Put on sterile gloves: Clean gloves are sufficient for enema administration. This is a clean, not sterile, procedure.

C. Hang the enema container 61 cm (24 in) above the anus: The correct height is no more than 45 cm (18 inches) to prevent rapid flow and discomfort.

D. Insert the tubing about 15 cm (6 in) into the anus: Insertion should be 7.5 to 10 cm (3 to 4 inches) in adults. Inserting 6 inches increases the risk of injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a 24-hr urine collection from a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who has received treatment for kidney stones. The nurse should remind the client to increase intake of which of the following?

A nurse is caring for older adult clients at a long-term care facility. Which of the following assessments should the nurse consider when monitoring clients for urinary retention?

A nurse is assisting with teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

A nurse is reinforcing teaching with a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

A nurse has completed providing care for a client who has a new colostomy determines the patient education is ready to learn how to care for it himself. Which of the following outcomes should the nurse expect?

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