A nurse is caring for a client who has an NG tube due to an intestinal obstruction. Using the nursing process for clinical decision making, which of the following actions should the nurse take to maintain NG patency?
Place the client on his right side if tube resistance occurs.
Check the tube patency every 4 hr.
Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr.
Maintain the client in a supine position.
The Correct Answer is B
A) Place the client on his right side if tube resistance occurs: Positioning the client on the right side can help facilitate gastric emptying, but it is not a primary action to ensure NG tube patency. If tube resistance occurs, the nurse should assess and address the resistance more directly.
B) Check the tube patency every 4 hr: Regularly checking the tube patency ensures that the NG tube remains open and functional, preventing blockages and ensuring continuous decompression or feeding as required.
C) Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr: Flushing the tube helps maintain patency, but the amount and frequency may vary based on facility protocols. Flushing every 8 hours might not be frequent enough to prevent blockages.
D) Maintain the client in a supine position: Keeping the client in a supine position is not recommended for maintaining NG tube patency and may increase the risk of aspiration. A semi-Fowler's position is usually preferred to promote drainage and reduce aspiration risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply dry heat to help the lesions scab over.: Applying dry heat is not a recommended treatment for herpes simplex lesions. Moist heat, such as sitz baths, can help alleviate discomfort and promote healing.
B. Take three sitz baths each day to alleviate symptoms.: Sitz baths can help soothe and clean the affected area, providing relief from pain and itching associated with herpes simplex virus lesions. This is an appropriate recommendation for symptom management.
C. Apply talcum powder to the perineal area to help the lesions dry.: Talcum powder is not recommended for herpes simplex lesions as it can irritate the skin and worsen symptoms. Keeping the area dry can be beneficial, but using powders is not advised.
D. You can resume intercourse with the use of natural membrane condoms.: Condoms may reduce the risk of transmission but do not eliminate it completely. It is generally advised to avoid sexual activity during an outbreak to prevent spreading the virus.
Correct Answer is A
Explanation
A) "Limit fluids that contain electrolytes":
For a client with gastroenteritis, it is crucial to maintain hydration due to the risk of dehydration from diarrhea and vomiting. However, fluids containing electrolytes can help replenish lost electrolytes and are beneficial. The instruction to "limit" these fluids might be misunderstood as a need to avoid them, which is not appropriate. The aim should be to encourage adequate hydration with fluids that contain electrolytes.
B) "Eliminate sources of probiotics from the diet":
Probiotics can help restore the balance of gut bacteria and may be beneficial in managing gastroenteritis. Eliminating probiotics from the diet is not typically recommended and may not support the recovery process.
C) "Take docusate sodium twice daily":
Docusate sodium is a stool softener, generally used to relieve constipation. In the context of gastroenteritis, which typically involves diarrhea, this medication is not appropriate and could worsen the condition.
D) "Avoid foods high in simple sugars":
Foods high in simple sugars can exacerbate diarrhea by increasing osmotic load in the intestines, leading to more water being drawn into the gut. Avoiding these foods can help manage and reduce symptoms of gastroenteritis.
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