A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take?

Attach the client's NG tube to low intermittent suction.

Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time.

Instill chilled lavage solution into the client's NG tube.

Use 0.9% sodium chloride for irrigation of the NG tube.

Answer and Explanation

The Correct Answer is B

A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.

B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.

C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.

D. While 0.9% sodium chloride is isotonic and can be used for irrigation, it is not typically the solution used for gastric lavage; water or a specific lavage solution is more appropriate.

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Correct Answer is C

Explanation

A. Muscle rigidity is not a typical manifestation of digoxin toxicity; it is more commonly associated with other conditions or medications.

B. Constipation can occur but is not a primary sign of digoxin toxicity.

C. Nausea is a common early sign of digoxin toxicity and should be included in the teaching. Other symptoms may include vomiting, visual disturbances, and confusion.

D. Wheezing is not associated with digoxin toxicity; it may suggest respiratory issues or an allergic reaction.

A. Apply a cold compress to the affected extremity. B. Teach the client to massage the affected extremity. C. Instruct the client to elevate the affected extremity when sitting. D. Assess pulses proximal to the affected area.

Correct Answer is C

Explanation

A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.

B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.

C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.

D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.

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A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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