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.
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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Related Questions
Correct Answer is D
Explanation
A. Providing interpretation services over the telephone is not effective for clients with hearing loss who may benefit more from in-person or visual communication.
B. Exaggerated lip movements can be distracting and may not aid understanding; clear and natural speech is more effective.
C. While providing written materials is helpful, ensuring the client can understand the material is key; using an appropriate reading level is essential but secondary to direct communication strategies.
D. Reducing environmental stimuli helps minimize distractions, making it easier for the client to focus on the nurse's speech or lip movements and improving overall communication.
Correct Answer is C
No explanation
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