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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Staying current on scheduled immunizations: While important for overall child health, staying current on immunizations is not a direct risk factor for sudden infant death syndrome (SIDS). Immunizations help prevent infections but do not specifically impact the likelihood of SIDS.
B) Maternal smoking during pregnancy: Maternal smoking during pregnancy is a significant risk factor for SIDS. Tobacco smoke exposure can negatively impact the baby's respiratory system and increase the risk of SIDS, making it crucial to address this risk factor.
C) Newborn who is large for gestational age: Being large for gestational age is not a recognized risk factor for SIDS. Risk factors for SIDS are more associated with environmental and prenatal conditions rather than birth weight alone.
D) Meconium staining of amniotic fluid: Meconium staining indicates potential fetal distress and complications during labor but is not a direct risk factor for SIDS. It is more related to the conditions surrounding birth rather than the risk of SIDS.
Correct Answer is B
Explanation
A) "Wash hands for 10 seconds after caring for the client.": Proper hand hygiene is critical in preventing the spread of infections, but the recommended duration for handwashing is at least 20 seconds. This option does not specify the necessary steps to ensure effective hand hygiene.
B) "Monitor the client for manifestations of dehydration.": Older adults are at a higher risk of dehydration due to gastroenteritis, which can cause significant fluid loss through vomiting and diarrhea. Monitoring for signs of dehydration, such as dry mucous membranes, decreased skin turgor, and reduced urine output, is a priority in managing their condition and preventing complications.
C) "Use toilet paper to remove stool from the client's skin.": While keeping the client clean is important, using toilet paper might not be sufficient or gentle enough to effectively clean and protect the skin. Using appropriate cleansing methods and skin care products is better for maintaining skin integrity.
D) "Administer diphenoxylate/atropine to the client.": While this medication can help reduce diarrhea, it may not be the first action to take. In some cases, stopping diarrhea too quickly can prevent the elimination of harmful pathogens. Monitoring and addressing hydration status is more critical initially in the management of gastroenteritis.
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