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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Performing hand hygiene frequently and consistently is the most effective way to prevent the spread of pathogens during patient care. Hand hygiene is the single most important measure to reduce the transmission of harmful germs and prevent health care-associated infections.
Choice B rationale
Properly disposing of contaminated equipment is important in preventing the spread of pathogens, but it is not the most effective measure. While it is crucial to handle and dispose of contaminated equipment properly, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice C rationale
Discarding used syringes in appropriate containers is a standard safety measure in healthcare settings, but it is not the most effective way to prevent the spread of pathogens during patient care. While it is important for preventing needlestick injuries and the spread of bloodborne pathogens, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice D rationale
Changing soiled linens daily for patients with draining wounds is a part of standard wound care and infection control, but it is not the most effective way to prevent the spread of pathogens during patient care. Hand hygiene remains the most effective measure in preventing the spread of pathogens.
Correct Answer is B
Explanation
Choice A rationale
Airborne precautions are used for diseases that are spread by tiny droplets caused by coughing and sneezing. HIV is not spread through the air, so airborne precautions are not necessary.
Choice B rationale
Standard precautions are used for all patient care. They’re based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. HIV is transmitted by direct or indirect contact with infected blood or body fluids. Therefore, the nurse should plan to implement standard precautions when caring for this patient.
Choice C rationale
Droplet precautions are used for diseases that are spread by large droplets caused by coughing, sneezing, talking, or procedures such as suctioning and bronchoscopy. HIV is not spread through these methods, so droplet precautions are not necessary.
Choice D rationale
Contact precautions are used for diseases that are spread by direct contact with the patient or indirect contact with environmental surfaces or patient care items. HIV is not spread through casual contact, so contact precautions are not necessary.
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