A nurse is caring for a client who has a nasogastric tube. The nurse should monitor the client for which of the following findings?

Fluid overload

Metabolic acidosis

Hyponatremia

Constipation

Answer and Explanation

The Correct Answer is C

A. Fluid overload: While NG tubes can be used for enteral feeding, they are often associated with fluid losses from suctioning or drainage rather than overload. Clients with NG tubes are more prone to dehydration and electrolyte imbalances.

B. Metabolic acidosis: NG tube suctioning primarily removes gastric contents, which are rich in hydrochloric acid. This can lead to metabolic alkalosis rather than acidosis due to excessive loss of acidic gastric secretions.

C. Hyponatremia: Prolonged NG tube suctioning or drainage can lead to the loss of sodium-rich gastric secretions, resulting in hyponatremia. Monitoring electrolyte levels and replacing lost fluids appropriately is essential to prevent imbalances.

D. Constipation: NG tubes are more commonly associated with diarrhea due to enteral feeding formulas rather than constipation. However, reduced oral intake and immobility could contribute to constipation in some cases.

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Correct Answer is D

Explanation

A. Discontinue opioids before trying nonpharmacological methods of pain relief: Nonpharmacological interventions can be used alongside opioids to enhance pain relief. Abruptly discontinuing opioids can lead to withdrawal symptoms and inadequate pain control.

B. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus: While heat and cold therapy can provide temporary relief, their effects typically last for a short duration, usually around 15 to 30 minutes after removal.

C. Use imagery with clients who have difficulty with focus and concentration: Guided imagery requires cognitive focus and the ability to concentrate. Clients with impaired attention may struggle to benefit from this technique.

D. Distraction changes the client's perception of pain, but it does not affect the cause: Distraction techniques, such as music or conversation, help shift the client's attention away from pain, altering perception but not addressing the underlying pathology.

A. Prepare the client for surgery. B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride. C. Obtain the client's vital signs every 5 min until the provider arrives. D. Raise the head of the bed to 20°.

Correct Answer is B

Explanation

A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.

B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.

C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.

D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.

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A nurse is caring for a client who has a nasogastric tube. The nurse should monitor the client for which of the following findings?

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