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 D

A. Attach the client's NG tube to low intermittent suction: Suction may be used after lavage for decompression, but during lavage, the focus is on instilling and withdrawing solution manually to clear the stomach of blood or contents.
B. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time: This volume is excessive and could increase the risk of aspiration or discomfort. Typically, 100–200 mL is used per instillation.
C. Instill chilled lavage solution into the client's NG tube: Chilled solutions are not recommended as they may induce hypothermia and have not been shown to effectively control bleeding. Room-temperature solution is preferred.
D. Use 0.9% sodium chloride for irrigation of the NG tube: Isotonic saline is the recommended solution for gastric lavage, as it helps prevent electrolyte imbalance and irritation.

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Correct Answer is B

Explanation

While a home health nurse visit is important, it is not an immediate safety concern for the client's discharge.

B. The need for assistance when transferring is critical information as it directly impacts the client's safety during discharge; the oncoming nurse must ensure proper support is arranged.

C. The fact that the client's partner will bring clothes is relevant but does not affect the immediate care of the client.

D. Encouragement for personal hygiene is important but is not as urgent as ensuring the client can safely transfer without risk of falls or injury.

A. Compensated metabolic acidosis B. Compensated respiratory acidosis C. Uncompensated respiratory acidosis D. Uncompensated metabolic acidosis

Correct Answer is C

Explanation

A. Compensated metabolic acidosis would show a normal pH with a decrease in HCO3- and a decrease in PaCO2.

B. Compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and a compensatory increase in HCO3-.

C. The low pH indicates acidosis, and the elevated PaCO2 suggests that it is respiratory in origin, with the HCO3- remaining normal, indicating no compensation has occurred yet.

D. Uncompensated metabolic acidosis would present with a low pH, low HCO3-, and normal PaCO2.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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