A nurse is caring for a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

Flush the tube with 0.9% sodium chloride.

Replace the NG tube every 24 hr.

Position the client supine in bed.

Increase the suction pressure as tolerated.

Answer and Explanation

The Correct Answer is A

A.   Flushing the NG tube with 0.9% sodium chloride helps maintain patency and prevents obstruction. It is a standard practice to flush NG tubes before and after administering medications or feedings.
B.   NG tubes are not routinely replaced every 24 hours unless there is a specific clinical indication to do so.
C.   The position of the client depends on the clinical situation, but supine position alone does not address NG tube care.
D.   Suction pressure should be set according to the physician's orders and the patient's tolerance, but it should not be increased arbitrarily without clinical indication.

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Correct Answer is ["B","C","E","G","H"]

Explanation

A. Nausea, while uncomfortable, is a common symptom during pregnancy and should be addressed, but it is not as urgent as the other symptoms in this context.

B. The deep tendon reflex (DTR) being 3+ bilaterally indicates hyperreflexia, which can be associated with conditions like preeclampsia, hence the need for follow-up.
C. The elevated blood pressure reading of 148/94 mm Hg is indicative of hypertension, which could be a sign of preeclampsia, a serious pregnancy complication.
D. The fetal heart tracing, while important, does not show immediate concern with a rate of 140/min, which is within normal limits.
E. The weight gain of 0.68 kg (1.5 lb) within the last week is significant and could be indicative of fluid retention, which is concerning in the context of the client's other symptoms.
F. The respiratory rate of 20/min falls within the normal range, and there are no other indications of respiratory distress or abnormalities in the assessment findings provided. Therefore, respiratory assessment is not a priority for follow-up at this time.
G. The fundal height measurement of 29 cm is appropriate for 30 weeks of gestation, but given the other symptoms, it should be monitored for any rapid changes.
H. The presence of 1+ dependent edema noted bilaterally suggests fluid retention, which is a concerning finding and warrants further assessment to evaluate for signs of preeclampsia or other complications.

A. Circulatory overload B. Extravasation C. Phlebitis D. Infiltration

Correct Answer is C

Explanation

A. Circulatory overload is characterized by symptoms such as dyspnea, crackles, and increased blood pressure, rather than localized redness and warmth.
B. Extravasation refers to the leakage of IV fluid into surrounding tissue, causing swelling and pain.
C. Redness and warmth around the peripheral catheter insertion site are indicative of phlebitis, which is inflammation of the vein. It's essential to document this finding accurately to monitor for worsening or complications.
D. Infiltration occurs when IV fluid leaks into the surrounding tissue, but it typically presents with swelling, pallor, and coolness at the site rather than redness and warmth.

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A nurse is caring for a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation Exhibits Select the 5 findings that require follow up by the nurse

Correct Answer is ["B","C","E","G","H"]

Explanation

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Explanation

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