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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A temperature of 37.6°C is normal post-surgery, not requiring reporting; low urinary output is urgent. Assuming temperature is concerning risks overlooking renal issues, potentially delaying intervention, critical to avoid in ensuring comprehensive postoperative monitoring and client safety after abdominal surgery.
Choice B reason: Serous drainage is expected post-abdominal surgery, indicating normal healing, not requiring reporting. Low urinary output is priority. Assuming drainage is urgent risks misprioritizing, potentially neglecting renal complications, critical to prevent in ensuring proper postoperative care and recovery in surgical clients.
Choice C reason: Urinary output of 20 mL/hr is below normal (30-50 mL/hr), indicating potential renal impairment or dehydration post-surgery, requiring immediate reporting. This ensures timely intervention, critical for preventing kidney injury, maintaining fluid balance, and supporting recovery in clients post-abdominal surgery.
Choice D reason: Blood pressure of 100/70 mm Hg is low but not critical unless symptomatic; low urinary output is more urgent. Assuming blood pressure requires reporting risks overlooking renal issues, critical to avoid in ensuring prioritized monitoring and intervention in postoperative abdominal surgery clients.
Correct Answer is C
Explanation
Choice A reason: Wrapping sterile gauze for bleeding is inappropriate; gentle pressure and provider notification are needed. Petroleum jelly prevents adhesion. Using gauze risks infection or trauma, critical to avoid in ensuring safe circumcision healing, supporting parental care, and preventing complications in newborns post-procedure.
Choice B reason: Removing yellow exudate, a normal healing sign, risks disrupting the circumcision site, causing pain or infection. Petroleum jelly is correct. Assuming removal is needed risks delayed healing, critical to prevent in ensuring proper wound care and parental education for newborns post-circumcision.
Choice C reason: Applying petroleum jelly to the glans with diaper changes prevents diaper adhesion, promotes healing, and reduces discomfort post-circumcision. This instruction is critical for parental care, ensuring infection prevention, supporting newborn comfort, and facilitating proper healing in the sensitive post-procedure period.
Choice D reason: Using soap on the circumcision site risks irritation and delayed healing; gentle water cleansing is preferred. Petroleum jelly is appropriate. Assuming soap is safe risks discomfort or infection, critical to avoid in ensuring proper care and healing for newborns following circumcision procedures.
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