A nurse is contributing to the plan of care of a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?

Avoid replacing the NG tube if it is accidentally dislodged.

Irrigate the blue pigtail port with sterile saline.

Verify tube placement by injecting air into the larger lumen.

Avoid the nares when providing hygiene care.

Answer and Explanation

The Correct Answer is A

A. Avoid replacing the NG tube if it is accidentally dislodged: After a gastrectomy, improper placement or reinsertion of the NG tube can disrupt the surgical site, leading to complications such as bleeding, leakage, or perforation. If the tube is accidentally dislodged, the nurse should notify the surgeon or provider, as reinsertions in postoperative gastric surgery clients are typically performed under their direction.

B. Irrigate the blue pigtail port with sterile saline: The blue pigtail port (air vent) of a double-lumen NG tube (e.g., Salem sump) should not be irrigated with saline because it functions as an air vent to prevent suction from damaging the stomach lining.

C. Verify tube placement by injecting air into the larger lumen: Injecting air to verify NG tube placement is no longer considered a reliable or evidence-based practice. Placement should be verified by other methods, such as aspiration of gastric contents, pH testing, or radiographic confirmation, especially in postoperative clients.

D. Avoid the nares when providing hygiene care: Hygiene care for the nares is essential to prevent skin breakdown and discomfort in clients with an NG tube. Neglecting the nares could lead to excoriation, pressure injuries, or infection.

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Correct Answer is B

Explanation

A. Headache
Headache is not a common side effect of lactulose.

B. Diarrhea
Lactulose is a laxative often prescribed for patients with cirrhosis to prevent or treat hepatic encephalopathy. Its primary side effect is diarrhea, which helps remove excess ammonia from the body, a substance that can exacerbate encephalopathy in patients with liver disease.

C. Peripheral edema
Peripheral edema is not a typical side effect of lactulose.

D. Dry mouth
Dry mouth is not a typical side effect of lactulose.

Correct Answer is ["10"]

Explanation

To calculate the number of milliliters (mL) of the hydroxyzine oral suspension to administer, you can use the following formula:

Dose (mL) = Ordered Dose (mg)/ Stock Concentration (mg/mL)

In this case:

- Ordered Dose = 50 mg

- Stock Concentration = 25 mg/5 mL

First, calculate the mg per mL from the stock concentration:

mg per mL = 25 mg/ 5 mL= 5 mg/mL

Now, use the formula to find the mL to administer:

Dose (mL) = 50 mg/ 5 mg/mL = 10 mL

So, the nurse should administer 10 mL of hydroxyzine oral suspension.

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A nurse is contributing to the plan of care of a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is preparing to administer hydroxyzine HCL 50 mg PO. Available is hydroxyzine oral suspension 25 mg/5 mL. How many ml. should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

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