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

Answer and Explanation

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.

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Correct Answer is ["A","D","E"]

Explanation

A. Perform leg exercises every 2 hr:
After surgery, especially abdominal surgery, patients are at risk of developing deep vein thrombosis (DVT) due to decreased mobility. Performing leg exercises every 2 hours helps in improving blood circulation and preventing blood clots in the legs.

B. Irrigate the nasogastric tube every 4 to 8 hr:
Irrigating the nasogastric tube (inserting fluid into the tube) at regular intervals is not a standard practice. Nasogastric tubes are primarily used for decompression (removing stomach contents) or drainage, not for irrigation. Inserting fluids without a specific medical reason can disrupt the balance in the gastrointestinal tract and lead to complications.

C. Maintain bed rest for 48 hr following surgery:
Encouraging early mobility is a standard practice after surgery. Prolonged bed rest increases the risk of complications such as pneumonia, blood clots, and muscle weakness. Patients are typically encouraged to start moving and walking around as soon as it's safe to do so, usually within a few hours to a day after surgery, depending on the type of surgery and the patient's overall condition.

D. Encourage hourly use of an incentive spirometer while awake:
An incentive spirometer is a medical device used to help patients improve the functioning of their lungs. It encourages patients to take slow, deep breaths, which helps in expanding the lungs and preventing atelectasis (partial lung collapse) that can occur after surgery when patients may not be taking deep breaths as usual.

E. Document the color, consistency, and amount of nasogastric drainage:
Monitoring and documenting the characteristics of nasogastric drainage is essential for assessing the patient's condition. Changes in the color, consistency, or amount of drainage can indicate various issues, including bleeding, infection, or bowel perforation. This documentation helps the healthcare team make informed decisions about the patient's care.

A. Perform leg exercises every 2 hr. B. irrigate the nasogastric tube every 4 to 8 hr. C. Maintain bed rest for 48 hr following surgery. D. Encourage hourly use of an incentive spirometer while awake. E. Document the color, consistency, and amount of nasogastric drainage.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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