A nurse is participating in the care plan for a patient with an intestinal obstruction who is undergoing continuous gastrointestinal decompression using a nasogastric tube.
What interventions should the nurse include in the care plan?

Daily measurement of abdominal girth.

Maintenance of the patient in Fowler’s position.

Moistening the patient’s lips with lemon glycerin swabs.

Use of sterile water to irrigate the nasogastric tube.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Daily measurement of abdominal girth is crucial in patients with an intestinal obstruction undergoing continuous gastrointestinal decompression. This is because any changes in the abdominal girth can indicate an improvement or worsening of the obstruction. Regular monitoring allows for timely intervention and adjustment of the care plan.

Choice B rationale

Maintaining the patient in Fowler’s position can help promote the drainage of gastric contents via the nasogastric tube. This position, where the patient is seated in bed at an angle of 45-60 degrees, uses gravity to assist in the drainage process, thereby potentially alleviating discomfort and reducing the risk of aspiration.

Choice C rationale

Moistening the patient’s lips with lemon glycerin swabs is not recommended. While it’s important to keep the patient’s lips moist to prevent dryness and cracking due to the nasogastric tube, lemon glycerin swabs can potentially dry out the lips more and cause irritation.

Choice D rationale

Using sterile water to irrigate the nasogastric tube is a standard practice in managing patients with a nasogastric tube. This helps ensure the patency of the tube and prevent blockages, allowing for effective gastrointestinal decompression.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.

Choice B rationale

Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.

Choice C rationale

Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.

Choice D rationale

Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.

A. Increased glucose B. Blood creatinine 0.6 mg/dL C. Blood osmolarity 260 mOsm/kg D. Urine Specific gravity 1.035 .

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

Explanation

Choice A rationale

Increased glucose levels can be a sign of dehydration. When the body is dehydrated, it can cause blood sugar levels to rise.

Choice B rationale

A blood creatinine level of 0.6 mg/dL is within the normal range and does not typically indicate dehydration.

Choice C rationale

An increased blood osmolarity, such as 260 mOsm/kg, can be a sign of dehydration. When the body is dehydrated, the concentration of solutes in the blood can increase, leading to higher osmolarity.

Choice D rationale

A high urine specific gravity, such as 1.035, can indicate dehydration. This measurement reflects the concentration of solutes in the urine, and a high value can mean that the body is conserving water due to dehydration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is participating in the care plan for a patient with an intestinal obstruction who is undergoing continuous gastrointestinal decompression using a nasogastric tube. What interventions should the nurse include in the care plan?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

An LPN is reviewing the laboratory tests results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration. Select all that apply.

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

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a 20-year-old college student with a 2-year history of bulimia nervosa. The student tells the nurse, “I know my eating binges and vomiting are not normal, but I can’t do anything about them.”. What would be a therapeutic response from the nurse?

A charge nurse is observing a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions by the nurse should prompt the charge nurse to intervene?

A nurse is getting ready to administer intravenous fluids. Which of the following actions should the nurse take to prevent electrical hazards?

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?

A nurse is examining the laboratory results for a client who had a urinalysis. Which finding should the nurse communicate to the provider?

A nurse is reviewing the laboratory values of a patient receiving total parenteral nutrition (TPN). The glucose is 72 mg/dL, chloride is 100 mEq/L, sodium is 138 mEq/L, and potassium is 3.0 mEq/L. What action should the nurse plan to take?

A nurse is assisting with teaching a client about dietary choices. Which of the following should be included in the teaching?

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse’s priority?

A nurse is participating in the care plan for a patient with an intestinal obstruction who is undergoing continuous gastrointestinal decompression using a nasogastric tube.
What interventions should the nurse include in the care plan?