A nurse is caring for a client who has a nasogastric (NG) tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?

Reposition the NG tube.

Inject 20 mL of air and aspirate in the NG tube.

Instill an irrigation solution slowly.

Check the functioning of the suction equipment.

Answer and Explanation

The Correct Answer is D

Choice A reason: Repositioning the NG tube is a later step; checking suction function is first, as equipment failure is a common cause of no drainage. Assuming repositioning is initial risks delaying simple fixes, potentially prolonging discomfort, critical to avoid in ensuring effective gastric decompression.

Choice B reason: Injecting air and aspirating is a troubleshooting step but follows checking suction equipment, which may resolve no drainage. Assuming air injection is first risks unnecessary intervention, potentially causing discomfort, critical to prevent in ensuring efficient NG tube management for gastric decompression.

Choice C reason: Instilling irrigation solution is a later step after confirming suction function, as equipment issues are more common. Assuming irrigation is first risks clogging or discomfort, critical to avoid in ensuring proper NG tube function and effective gastric decompression in clients with non-draining tubes.

Choice D reason: Checking suction equipment function is the first step for a non-draining NG tube, as equipment failure is a common issue, easily corrected. This ensures effective decompression, critical for preventing gastric distention, supporting client comfort, and guiding further troubleshooting in managing NG tube care.

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Correct Answer is C

Explanation

Choice A reason: A communication board is for speech or cognitive issues, not visual impairment, where indirect lighting aids vision. Assuming a board is appropriate risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear interaction for visually impaired clients in care settings.

Choice B reason: An interpreter is for language barriers, not visual impairment, where indirect lighting enhances visibility. Assuming an interpreter is needed risks misaligned communication strategies, potentially reducing clarity, critical to prevent in ensuring effective teaching and interaction for clients with visual impairments.

Choice C reason: Indirect lighting reduces glare, improving visibility for visually impaired clients, enhancing communication and safety. This understanding is critical for effective interaction, ensuring client comfort, promoting independence, and supporting accurate information exchange, essential for care delivery in clients with visual impairments.

Choice D reason: Collaborating with a speech therapist addresses speech issues, not visual impairment, where indirect lighting is key. Assuming therapist involvement is relevant risks overlooking visual needs, potentially reducing communication efficacy, critical to avoid in supporting visually impaired clients in healthcare settings.

A. Place the client in a supine position while resting. B. Perform an ECG every 12 hours. C. Draw a troponin level every 4 hours. D. Obtain a cardiac rehabilitation consultation.

Correct Answer is D

Explanation

Choice A reason: Supine positioning risks respiratory strain post-myocardial infarction; semi-Fowler’s is preferred. Cardiac rehabilitation is appropriate. Assuming supine is correct risks discomfort or complications, critical to avoid in ensuring proper positioning and recovery support for clients 3 days post-acute myocardial infarction.

Choice B reason: ECG every 12 hours is excessive 3 days post-myocardial infarction unless symptomatic; daily or as-needed is standard. Rehabilitation consultation is key. Assuming frequent ECGs risks unnecessary testing, critical to prevent in focusing on recovery planning and rehabilitation for post-infarction clients.

Choice C reason: Troponin levels every 4 hours are unnecessary 3 days post-myocardial infarction, as levels peak earlier; rehabilitation is priority. Assuming frequent troponin checks risks redundant testing, critical to avoid in ensuring appropriate care focus on recovery and rehabilitation post-acute myocardial infarction.

Choice D reason: Obtaining a cardiac rehabilitation consultation 3 days post-myocardial infarction supports recovery through structured exercise and education, critical for preventing further events. This intervention promotes long-term cardiac health, essential for reducing readmissions, enhancing recovery, and improving quality of life in post-infarction clients.

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A nurse is caring for a client who has a nasogastric (NG) tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?

Nursing Test Bank

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