A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take.
Chill the lavage fluid before instilling it.
Position the client on his right side.
Withdraw the fluid manually until it is clear.
Insert a small-bore NG tube.
The Correct Answer is C
Choice A rationale
Chilling the lavage fluid causes vasoconstriction of the gastric blood vessels, which helps to slow or stop the bleeding. The cold temperature directly constricts the capillaries and arterioles in the stomach lining, reducing blood flow to the bleeding site. This action is a primary goal of gastric lavage in cases of upper gastrointestinal hemorrhage.
Choice B rationale
Positioning the client on their left side is the appropriate action. This position allows the lavage fluid to pool in the greater curvature of the stomach, where it can be most effective at washing over the bleeding site. Placing the client on their right side would cause the fluid to quickly pass into the duodenum, which is less effective for gastric lavage.
Choice C rationale
Gastric lavage is performed to remove blood and clots from the stomach. The procedure involves instilling a fluid, typically saline, and then withdrawing it. The nurse continues this process, manually withdrawing the fluid, until the return fluid is clear or only slightly pink, which indicates that the bleeding has been controlled or significantly reduced.
Choice D rationale
A large-bore NG tube (16-18 French or larger) is preferred for gastric lavage in cases of upper gastrointestinal bleeding. A large-bore tube is necessary to effectively remove blood clots and viscous fluid from the stomach. A small-bore tube would easily become occluded by clots, rendering the lavage procedure ineffective. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Antacids containing mint, such as peppermint, can actually worsen the symptoms of GERD. Mint is known to relax the lower esophageal sphincter, which allows stomach acid to reflux into the esophagus more easily. This can increase heartburn and discomfort, so it should be avoided.
Choice B rationale
Chocolate contains methylxanthines, which can decrease the pressure of the lower esophageal sphincter, allowing stomach contents to reflux into the esophagus. This can trigger or worsen GERD symptoms like heartburn and regurgitation. Therefore, clients with GERD should limit or avoid consuming foods containing chocolate to minimize symptom severity.
Choice C rationale
Lying down after eating can exacerbate GERD symptoms because it allows gravity to work against the lower esophageal sphincter, making it easier for stomach acid to flow back into the esophagus. Clients should remain upright for at least 3 hours after a meal to aid digestion and prevent reflux.
Choice D rationale
Citrus fruits are highly acidic and can irritate the already inflamed esophageal lining in a client with GERD, leading to increased pain and discomfort. Consuming acidic foods can worsen heartburn symptoms and should be limited or avoided to manage the condition effectively. *.
Correct Answer is A
Explanation
Choice A rationale
The first step in inserting an indwelling urinary catheter, after gathering supplies and preparing the client, is to lubricate the tip. The application of a generous amount of water-soluble gel to the catheter tip reduces friction as it passes through the urethra. This is crucial for minimizing trauma to the urethral mucosa and decreasing client discomfort during insertion.
Choice B rationale
Positioning the sterile drape is a later step in the procedure, after the catheter has been prepared for insertion. The drape is used to create a sterile field and isolate the perineum. This helps prevent contamination of the sterile catheter and gloves from surrounding non-sterile areas, which is essential for maintaining sterility and preventing infection.
Choice C rationale
Cleansing the meatus with an antiseptic solution is a critical step, but it is performed after the catheter is lubricated and the sterile field is established. This action mechanically and chemically removes microorganisms from the perineal area, reducing the risk of introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Attaching a prefilled syringe to the inflation hub is done after the catheter is fully inserted into the bladder and urine flow is established. This step is necessary to inflate the balloon, which secures the catheter in place and prevents it from being expelled. Doing this prematurely could cause urethral damage. *.
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