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.

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Correct Answer is C

Explanation

A) Use petroleum jelly on a cotton ball to plug your ear when shampooing.
This method can help protect the ear from water exposure during showering or shampooing. However, it doesn't address trauma or hearing impairment prevention as effectively as avoiding pressure changes.

B) Clean dried blood in your ear canal with a cotton-tipped applicator.
Using cotton-tipped applicators can cause trauma to the ear canal and potentially disrupt the surgical site, increasing the risk of complications and impairing hearing.

C) Avoid blowing your nose for 1 month after surgery.
Avoiding nose blowing is crucial because it can create pressure changes in the ear that may disrupt the healing process and cause trauma to the surgical site, leading to potential hearing impairment.

D) Notify your provider if you have popping or crackling sensations in the affected ear.
Popping or crackling sensations can be normal as the ear heals and adjusts post-surgery. While it’s important to monitor symptoms, reporting them is not necessarily about preventing trauma or hearing impairment.

A. Hispanic ethnicity B. Cholesterol 190 mg/dL C. BMI of 28 D. History of atrial fibrillation.

Correct Answer is C

Explanation

A) Hispanic ethnicity: While ethnicity can influence the prevalence and risk of hypertension, Hispanic ethnicity alone is not a direct risk factor for hypertension. Other factors such as lifestyle, diet, and genetic predispositions play more significant roles in the development of hypertension.

B) Cholesterol 190 mg/dL: Although elevated cholesterol levels can contribute to cardiovascular disease, a cholesterol level of 190 mg/dL is considered borderline high but not a primary risk factor for hypertension. The risk for hypertension is more directly related to factors like blood pressure levels and weight.

C) BMI of 28: A Body Mass Index (BMI) of 28 falls into the overweight category, which is a known risk factor for developing hypertension. Excess body weight can increase blood pressure by increasing the workload on the heart and contributing to insulin resistance, which can further elevate blood pressure.

D) History of atrial fibrillation: While atrial fibrillation is a significant cardiac condition and can be associated with other cardiovascular risks, it is not a direct risk factor for the development of hypertension. The primary risk factors for hypertension include factors like obesity, diet, and physical inactivity.

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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

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