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A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.

Which of the following actions should the nurse perform first?

Replace the NG tube.

Provide oral hygiene care.

Administer an antiemetic

Evaluate functioning of the suction device

Answer and Explanation

The Correct Answer is D

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

Prompt assessment of the suction device is crucial to determine if it's functioning properly. If the suction is inadequate, it can lead to gastric contents accumulating and potentially causing vomiting.
Assessing the suction device first allows for timely intervention if it's not working correctly, preventing further complications and discomfort for the client.

Choice A rationale:

Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.

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Correct Answer is A

Explanation

The correct answer is A. Increase dietary calcium. Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.

Choice B is wrong because prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.

Choice C is wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomach.

Choice D is wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.

A. "Plan to take this medication with food." B. "Plan to take this medication with antacids." C. "Limit foods that contain vitamin D while taking this medication." D. "Limit foods that contain folic acid while taking this medication."

Correct Answer is A

Explanation

Choice A reason:

"Plan to take this medication with food." Is the correct statement. When providing instructions to an older adult client who has a seizure disorder and is prescribed phenytoin (an antiepileptic or anticonvulsant medication), the nurse should advise the client to take the medication with food. Phenytoin can cause gastrointestinal irritation, and taking it with food can help minimize this side effect.

Choice B reason:

"Plan to take this medication with antacids. “is not the appropriate instruction. Phenytoin should not be taken with antacids. Antacids can reduce the absorption of phenytoin, leading to decreased effectiveness of the medication. If antacids are needed for other reasons, they should be taken at least 2 hours before or after taking phenytoin.

Choice C reason:

"Limit foods that contain vitamin D while taking this medication. “This is not inappropriate instruction. There is no specific requirement to limit foods containing vitamin D while taking phenytoin. However, phenytoin may decrease the absorption of vitamin D, which could potentially affect the client's vitamin D levels. Therefore, it is essential for the client to have regular check-ups and possibly discuss the need for vitamin D supplementation with their healthcare provider.

Choice D reason:

"Limit foods that contain folic acid while taking this medication. “This is not the correct statement. Phenytoin can interfere with the absorption of folic acid (a B-vitamin). Long-term use of phenytoin may lead to folic acid deficiency. Therefore, the nurse should instruct the client to consume foods rich in folic acid and discuss the potential need for folic acid supplementation with their healthcare provider.

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A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

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A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited.

Which of the following actions should the nurse perform first?