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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Hiccups: Hiccups are not a common adverse effect of lisinopril. While they can be bothersome, they are not typically associated with this medication. Monitoring for more significant side effects is crucial, but hiccups alone are not usually indicative of a serious reaction.

B) Anxiousness: Anxiousness or anxiety is not a typical side effect of lisinopril. While anxiety can occur due to various factors, it is not directly linked to the use of lisinopril. The focus should be on more specific adverse effects related to the medication.

C) Cough: A persistent, dry cough is a well-documented adverse effect of lisinopril. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril can cause a cough due to the accumulation of bradykinin. This side effect is significant and often leads to discontinuation of the medication.

D) Rhinorrhea: Rhinorrhea, or a runny nose, is not a common adverse effect of lisinopril. Although it can occur with other conditions or medications, it is not specifically associated with ACE inhibitors. Monitoring for more characteristic side effects of lisinopril is important.

A. Administer risperidone 25 mg IM. B. Teach the client how to perform guided imagery. C. Stay with the client until the panic attack subsides. D. Encourage the client to take quick, shallow breaths.

Correct Answer is C

Explanation

A) Administering risperidone 25 mg IM is not typically appropriate for treating a panic attack. Risperidone is an antipsychotic medication used for treating conditions like schizophrenia and bipolar disorder, not for the immediate management of panic attacks. Immediate pharmacological intervention is not generally the first line of treatment in acute panic attacks unless the client has a specific medication prescribed for such episodes.

B) Teaching the client how to perform guided imagery can be beneficial for long-term anxiety management but is not the most effective intervention during an acute panic attack. During a panic attack, the client's ability to focus and learn new techniques may be impaired, making it less effective in the immediate situation.

C) Staying with the client until the panic attack subsides is the most appropriate action. Presence and reassurance from the nurse can help the client feel safer and more grounded. This approach provides emotional support and can help reduce the severity and duration of the panic attack by addressing the client's immediate need for security and stability.

D) Encouraging the client to take quick, shallow breaths can exacerbate hyperventilation and increase anxiety during a panic attack. Instead, slow, deep breathing techniques are recommended to help calm the client's physiological response and reduce the intensity of the panic attack.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypertension and is taking lisinopril. The nurse should monitor the client for which of the following findings as an adverse effect of lisinopril?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has acute kidney failure and is in a state of metabolic acidosis. The nurse should monitor for which of the following manifestations?

A nurse is counseling an older adult client whose partner died suddenly the previous month. The client cries periodically and rarely makes eye contact. Which of the following questions is the priority for the nurse to ask?

A nurse is providing preventative dietary teaching to a client who has a family history of cholelithiasis. Which of the following instructions should the nurse include?

A nurse is assessing a client's adaptation to a new diagnosis of osteoarthritis. Which of the following client statements should indicate to the nurse that the client is managing the disease?

A nurse in a provider's office is reviewing the medical record of a client. The nurse should identify which of the following findings as a risk factor for the development of hypertension?

A nurse is planning care using systematic desensitization for a client who has severe claustrophobia. Which of the following interventions should the nurse include in the plan of care?

A nurse is assessing a client who has an electrolyte imbalance with an elevated total calcium level of 12.8 mg/dL. Which of the following findings should the nurse expect?

A nurse is caring for a client who has an electrolyte imbalance with an elevated magnesium level of 3.3 mEq/L. Which of the following findings is the priority for the nurse to report to the provider?