A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

Maintain the client in Fowler’s position.

Use sterile water to irrigate the nasogastric tube.

Moisten the client’s lips with lemon-glycerin swabs.

Measure abdominal girth daily.

Answer and Explanation

The Correct Answer is A

Choice A: Maintain the client in Fowler’s position. This is correct because Fowler’s position, which is a semi-sitting position with the head of the bed elevated 45 to 60 degrees, can facilitate the drainage of gastric contents and reduce the risk of aspiration.

Choice B: Use sterile water to irrigate the nasogastric tube. This is incorrect because sterile water is not necessary to irrigate the nasogastric tube, unless the client is immunocompromised or has a high risk of infection. Tap water or normal saline can be used to irrigate the nasogastric tube, following the provider’s orders or the facility’s protocol.

Choice C: Moisten the client’s lips with lemon-glycerin swabs. This is incorrect because lemon-glycerin swabs can dry out and irritate the client’s lips and oral mucosa, especially if used frequently. The nurse should use water-soluble lubricant or lip balm to moisturize the client’s lips and mouth.

Choice D: Measure abdominal girth daily. This is incorrect because measuring abdominal girth daily is not enough to monitor the progression of the intestinal obstruction and the eﬀectiveness of the gastrointestinal decompression. The nurse should measure abdominal girth more frequently, such as every 4 hr or every shift, and report any changes or abnormalities.

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Correct Answer is C

Explanation

Choice A: Negative Chvostek’s sign is the absence of facial twitching when the facial nerve is tapped. This is a normal finding and does not indicate hypoparathyroidism. A positive Chvostek’s sign is a sign of hypocalcemia, which can occur in hypoparathyroidism.

Choice B: Flaccid muscles are weak and limp muscles that lack tone and resistance. This is not a typical finding of hypoparathyroidism, as low levels of parathyroid hormone can cause muscle spasms, cramps, and tetany.

Choice C: Numbness of the hands is a common finding of hypoparathyroidism, as low levels of parathyroid hormone can cause hypocalcemia, which aﬀects the nerve function and sensation. Numbness can also occur in the feet, lips, and tongue.

Choice D: Hypercalcemia is a high level of calcium in the blood. This is not a finding of hypoparathyroidism, as low levels of parathyroid hormone can cause hypocalcemia, which is a low level of calcium in the blood. Hypercalcemia can be a sign of hyperparathyroidism, which is the opposite condition of hypoparathyroidism.

A. Ketoacidosis B. Hyperglycemia C. Hypoglycemia D. Nephropathy

Correct Answer is C

Explanation

Choice A: Ketoacidosis. This is incorrect because ketoacidosis is a complication of hyperglycemia, not hypoglycemia. Ketoacidosis occurs when the body breaks down fat for energy due to insufficient insulin, resulting in the accumulation of ketones and acids in the blood. Ketoacidosis can cause symptoms such as nausea, vomiting, abdominal pain, fruity breath odor, deep and rapid breathing, and altered mental status.

Choice B: Hyperglycemia. This is incorrect because hyperglycemia is a condition of high blood glucose, not low blood glucose. Hyperglycemia can occur due to insufficient insulin, excessive carbohydrate intake, infection, stress, or illness. Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, blurred vision, fatigue, and headache.

Choice C: Hypoglycemia. This is correct because hypoglycemia is a condition of low blood glucose, which can occur due to excessive insulin, inadequate carbohydrate intake, exercise, alcohol consumption, or medication interactions. Hypoglycemia can cause symptoms such as sweating, tachycardia, palpitations, tremors, hunger, anxiety, confusion, dizziness, weakness, and seizures.

Choice D: Nephropathy. This is incorrect because nephropathy is a complication of chronic hyperglycemia, not acute hypoglycemia. Nephropathy is a kidney disease that results from damage to the small blood vessels and glomeruli in the kidneys due to high blood glucose levels. Nephropathy can cause symptoms such as proteinuria, edema, hypertension, and renal failure.

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A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

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