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.

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Correct Answer is B

Explanation

Choice A rationale

Respiratory alkalosis is typically associated with hyperventilation, which can occur in conditions such as anxiety, fever, or certain lung diseases. However, it is less likely in a patient who is nauseous and vomiting.

Choice B rationale

Metabolic alkalosis is a condition that can occur due to the loss of acid from the body, which can happen when a patient is vomiting. When a person vomits, they lose stomach acid (hydrochloric acid), and this can disrupt the acid-base balance in the body, leading to metabolic alkalosis.

Choice C rationale

Metabolic acidosis is typically associated with conditions that cause the accumulation of acid in the body or the loss of bicarbonate, such as kidney disease, lactic acidosis, or certain poisonings. It is less likely in a patient who is nauseous and vomiting.

Choice D rationale

Respiratory acidosis is typically associated with conditions that cause an inability to remove enough carbon dioxide from the body, such as chronic obstructive pulmonary disease (COPD) or airway obstruction. It is less likely in a patient who is nauseous and vomiting.

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.

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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 taking care of a patient who is nauseous and vomiting. Which of the following acid-base imbalances should the nurse identify the patient is at risk for?

Correct Answer is B

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

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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?