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 A

Explanation

A. Prior to percussing the abdomen:Auscultation should be performed before percussing or palpating the abdomen. Percussion and palpation can alter bowel activity, potentially leading to inaccurate assessment of bowel sounds.

B. Prior to inspecting the abdomen:Inspection should always be performed before auscultation when assessing the abdomen. This allows the nurse to observe any visible abnormalities, such as distention or skin changes, without altering bowel activity. Auscultation should follow inspection.

C. After checking for kidney tenderness:Checking for kidney tenderness (e.g., costovertebral angle tenderness) involves percussing the back and is not part of the sequence of a standard abdominal exam. It does not precede auscultation.

D. After palpating the abdomen:
Palpation can stimulate or alter bowel sounds, potentially leading to an inaccurate assessment. Therefore, auscultation should always occur before palpation.

A. Obtain the client's vital signs. B. Weigh the client. C. Change the client's dressing. D. Administer pain medication.

Correct Answer is D

Explanation

A. Obtain the client's vital signs:
Vital signs are essential for assessing the client's overall condition and can provide crucial information about the client's stability. However, in this scenario, there's a higher priority nursing action that needs immediate attention.

B. Weigh the client:
Daily weight measurement is important, especially in postoperative patients, to monitor for fluid retention or loss. However, this is not the most urgent action in this situation.

C. Change the client's dressing:
Changing the dressing involves maintaining the surgical site's cleanliness and preventing infections. While this is important, it's not the highest priority in this situation.

D. Administer pain medication:
Correct Choice. Addressing the client's pain is a priority to ensure their comfort and well-being, especially postoperatively. Managing pain effectively is crucial for the client's recovery and can facilitate other necessary activities, such as changing the dressing or weighing the client.

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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 checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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