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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Skin tenting: Skin that remains elevated after being pinched indicates poor skin turgor, a classic sign of dehydration.
B. BP 178/90 mm Hg: Elevated blood pressure is not associated with dehydration; dehydration usually causes low BP.
C. Jugular vein distention: JVD indicates fluid overload, not dehydration.
D. Red mucous membranes: Dehydration typically causes dry, sticky, or cracked mucous membranes, not redness.
Correct Answer is B
Explanation
A. Respiratory therapist: While helpful in respiratory management, they do not assess swallowing ability.
B. Speech therapist: A speech-language pathologist evaluates swallowing function and recommends dietary textures and techniques to reduce aspiration risk.
C. Physical therapist: Focuses on mobility and strength, not swallowing.
D. Dentist: May manage oral health, but does not evaluate or treat dysphagia.
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