A nurse is performing gastric lavage on a client using a large-bore NG tube. Which of the following actions should the nurse take?
Position the client on the right side.
Instill 1000 mL of sterile saline.
Withdraw fluid until it is clear.
Connect the NG tube to high continuous suction.
The Correct Answer is C
A. Positioning the client on the right side is not a standard recommendation for gastric lavage. The standard position is typically on the left side to facilitate the drainage of gastric contents.
B. Instilling 1000 mL of sterile saline is not a recommended action for gastric lavage. Gastric lavage involves the removal of stomach contents rather than instilling fluids.
C. Withdrawing fluid until it is clear is the correct action. Gastric lavage is a medical procedure used to empty the stomach contents. The process involves introducing small amounts of fluid (such as saline) into the stomach and then aspirating it back, along with gastric contents, until the aspirate is clear.
D. Connecting the NG tube to high continuous suction is not a standard approach for gastric lavage. Gastric lavage involves intermittent instillation and withdrawal of small amounts of fluid to clear the stomach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Warfarin:
Warfarin is an anticoagulant that works by inhibiting the synthesis of certain clotting factors, including factors II, VII, IX, and X. While it is used to prevent thromboembolic events, in a client with cirrhosis and an elevated PT, the priority is addressing the coagulation factor deficiency rather than adding an anticoagulant.
B. Vitamin K:
Vitamin K is the antidote for warfarin, and it helps in the synthesis of clotting factors. In cirrhosis, there can be impaired synthesis of clotting factors due to liver dysfunction. Administering vitamin K can aid in correcting coagulation abnormalities.
C. Heparin:
Heparin is another anticoagulant, but it does not reverse the effects of warfarin. It works by a different mechanism and is typically used in acute settings, such as deep vein thrombosis or pulmonary embolism. It is not the primary intervention for an elevated PT in cirrhosis.
D. Ferrous sulfate:
Ferrous sulfate is an iron supplement and is not indicated for the correction of an elevated PT. Iron supplements are typically used to address iron deficiency anemia.
Correct Answer is A
Explanation
A. Obstruction of the bile duct:
Biliary cirrhosis can result from chronic obstruction of the bile ducts, leading to damage to the liver tissue. This obstruction can be due to various causes, such as gallstones or strictures.
B. Hepatotoxic medications:
While certain medications can contribute to liver damage, biliary cirrhosis specifically refers to conditions affecting the bile ducts. Hepatotoxic medications may contribute to cirrhosis but not necessarily biliary cirrhosis.
C. Hepatitis C:
Hepatitis C is a viral infection that primarily affects the liver. While chronic hepatitis C infection can lead to cirrhosis, it is not synonymous with biliary cirrhosis.
D. Excessive alcohol consumption:
Excessive alcohol consumption is a common cause of cirrhosis, but biliary cirrhosis specifically refers to cirrhosis resulting from chronic obstruction of the bile ducts.
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