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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will take the medication for diarrhea."
This statement is incorrect. Docusate sodium is not used to treat diarrhea; it is a stool softener used to relieve constipation.
B. "I will have soft stools 1 to 3 days after starting this medication."
This statement indicates that the client understands the purpose of docusate sodium, which is a stool softener used to prevent constipation and to soften stool. It typically takes 1 to 3 days for the medication to produce the desired effect of softer stools.
C. "I will drink one half glass of water when I take the medication."
This statement is partially correct. Taking docusate sodium with a full glass of water is recommended, not half a glass, to ensure that the medication is properly absorbed and to prevent throat irritation.
D. "I can take this medication with mineral oil."
This statement is incorrect. Docusate sodium should not be taken with mineral oil because it can increase the absorption of mineral oil, leading to systemic effects.
Correct Answer is D
Explanation
A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.
B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.
C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.
D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.
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