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 D
Explanation
A) Double-bag the client's trash before removing it from the room: While double-bagging is a precaution used in certain infections to prevent contamination, it is not necessary for influenza. Influenza spreads via respiratory droplets rather than contact with contaminated objects. Standard waste disposal methods are typically sufficient to manage the risk of contamination from trash.
B) Place the client in a negative air pressure room with 6 to 12 air exchanges per hour: Negative air pressure rooms are designed to contain airborne pathogens by preventing contaminated air from escaping the room. Diseases such as tuberculosis or measles require this level of isolation. However, influenza spreads through droplets that settle quickly rather than remaining airborne, making negative air pressure rooms unnecessary for influenza isolation.
C) Ensure all air in the client's room is filtered through a HEPA filter: HEPA (High-Efficiency Particulate Air) filters are used to trap airborne particles. For influenza, which is spread by larger respiratory droplets, such filtration is not needed. The droplets are too large to remain suspended in the air and are typically spread through close contact, rather than requiring air filtration.
D) Wear a surgical mask when within 1 m (3 ft) of the client: This is the most appropriate precaution. Influenza is primarily spread through respiratory droplets that can travel about 1 meter (3 feet) when a person coughs, sneezes, or talks. Wearing a surgical mask within this distance helps prevent inhaling these droplets, thus reducing the risk of transmission. This aligns with droplet precautions which are standard for managing influenza.
Correct Answer is B
Explanation
A) "Suggest the client avoid snacking during the day.": Snacking can help maintain caloric intake and prevent malnutrition. It is generally beneficial for clients with wasting syndrome to have frequent, small meals and snacks throughout the day to increase overall caloric and nutrient intake.
B) "Encourage the client to rest before eating meals.": Resting before meals can help conserve energy, making it easier for clients with wasting syndrome to eat larger portions and improve their nutritional intake. Fatigue can significantly reduce appetite and meal consumption, so conserving energy for eating is a practical strategy.
C) "Instruct the client to consume 1 L of fluid daily.": Proper hydration is important, but 1 liter may be insufficient for overall hydration needs. Clients with AIDS and wasting syndrome should be encouraged to maintain adequate fluid intake to support overall health and aid in digestion, which typically requires more than 1 liter per day.
D) "Tell the client to increase the saturated fat content of each meal.": Increasing saturated fat content is not advisable as it can lead to other health complications such as cardiovascular disease. Instead, a balanced diet with healthy fats, proteins, and carbohydrates is more appropriate to address malnutrition in clients with wasting syndrome.
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