A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 ml. In the past 6 hr. The nurse should monitor the client for which of the following electrolyte Imbalances?
Decreased potassium level
Decreased calcium level
Elevated magnesium level
Elevated sodium level
The Correct Answer is A
A. Decreased potassium level
NG tube drainage can lead to hypokalemia (low potassium levels) due to the loss of gastric fluids, which contain significant amounts of potassium. This choice is correct.
B. Decreased calcium level
Calcium levels are not directly affected by NG tube drainage.
C. Elevated magnesium level
NG tube drainage does not typically lead to elevated magnesium levels.
D. Elevated sodium level
NG tube drainage can result in hyponatremia (low sodium levels) due to the loss of gastric fluids. Elevated sodium levels are not expected in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Perform leg exercises every 2 hr: Performing leg exercises every 2 hours is essential for preventing blood clots and maintaining circulation in immobile patients. This is especially important after surgery to prevent complications like deep vein thrombosis.
B. Irrigate the nasogastric tube every 4 to 8 hr: Irrigating the nasogastric tube is not a standard nursing practice and should not be done without a physician's order. The nasogastric tube is typically used for decompression, drainage, or feeding. If the tube becomes clogged or there are concerns about drainage, the nurse should contact the healthcare provider for further instructions.
C. Maintain bed rest for 48 hr following surgery: While some bed rest might be necessary immediately after surgery, the goal is to encourage mobility as soon as possible to prevent complications such as atelectasis and deep vein thrombosis. Patients are usually encouraged to mobilize as soon as they are medically stable, often within hours after surgery.
D. Encourage hourly use of an incentive spirometer while awake: Using an incentive spirometer helps prevent atelectasis and promotes lung expansion after surgery. Encouraging the patient to use the incentive spirometer hourly while awake is a common nursing intervention to maintain respiratory function postoperatively.
E. Document the color, consistency, and amount of nasogastric drainage: Documenting the color, consistency, and amount of nasogastric drainage is crucial for monitoring the patient's condition. Changes in these factors could indicate bleeding, infection, or other complications, and timely documentation helps healthcare providers assess the patient's status and make appropriate interventions.
Correct Answer is D
Explanation
A. Place the client in a supine position.
Placing the client in a high Fowler's position (sitting upright) is the appropriate position for inserting a nasogastric tube. This position helps facilitate the passage of the tube through the nasopharynx and into the esophagus and stomach.
B. Withdraw the tube if the client gags during insertion.
Gagging during insertion is a normal response. Advancing the tube slowly and having the client swallow can help pass the tube through the nasopharynx.
C. Measure the tube for insertion from the tip of the nose to the umbilicus.
The correct measurement for insertion is from the tip of the nose to the earlobe and then down to the xiphoid process (not the umbilicus).
D. Instruct the client to place his chin to his chest and swallow.
This instruction is appropriate. Asking the client to flex their head slightly forward and swallow helps guide the tube into the esophagus.
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