A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?

“Tube drainage should be rust-colored.”

“Nutrition will be provided through the tube.”

“The tube decreases pressure within the stomach.”

“The tube should be irrigated with sterile water.”

Answer and Explanation

The Correct Answer is C

Choice A Reason

“Tube drainage should be rust-colored.” This statement is incorrect. Normal NG tube drainage is typically greenish-yellow due to bile or clear if it is from the stomach. Rust-colored drainage could indicate bleeding and should be reported immediately.

Choice B Reason

“Nutrition will be provided through the tube.” This statement is incorrect. While NG tubes can be used for feeding, in the context of a postoperative colectomy, the primary purpose of the NG tube is usually to decompress the stomach and prevent nausea and vomiting. Enteral feeding is typically done through a different type of tube, such as a nasojejunal tube.

Choice C Reason

“The tube decreases pressure within the stomach.” This is the correct statement. An NG tube is often used postoperatively to decompress the stomach, which helps to reduce pressure, prevent vomiting, and allow the gastrointestinal tract to heal.

Choice D Reason

“The tube should be irrigated with sterile water.” This statement is partially correct but needs context. NG tubes should be irrigated to maintain patency, but the type of solution (sterile water, saline) can vary based on hospital protocol. The primary focus here is on the purpose of the NG tube rather than the irrigation technique.

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Correct Answer is B

Explanation

Choice A Reason

Apply an ice pack directly to the affected area. This statement is incorrect. Applying ice to a snake bite can cause more harm than good. Ice can restrict blood flow and potentially increase tissue damage. The recommended approach is to keep the bite area still and at or below heart level to slow the spread of venom.

Choice B Reason

Immobilize the affected extremity with a splint. This is the correct intervention. Immobilizing the affected limb helps to slow the spread of venom by reducing movement. Keeping the limb still and using a splint can prevent the venom from circulating more rapidly through the body.

Choice C Reason

Place a tourniquet above and below the affected area. This statement is incorrect. Using a tourniquet is not recommended for snake bites as it can cause severe damage to the affected limb by cutting off blood flow completely. This can lead to tissue death and other complications.

Choice D Reason

Elevate the affected extremity. This statement is incorrect. Elevating the limb can increase the spread of venom. The affected limb should be kept at or below heart level to slow the venom’s spread.

A. Place several pillows behind the client’s head. B. Place the client in a lateral semi-prone recumbent position. C. Keep the client’s neck in a midline position. D. Maintain flexion of the client’s hips at a 90-degree angle.

Correct Answer is C

Explanation

Choice A Reason

Place several pillows behind the client’s head. This intervention is incorrect. Placing several pillows behind the client’s head can lead to neck flexion, which can increase intracranial pressure by obstructing venous outflow from the brain.

Choice B Reason

Place the client in a lateral semi-prone recumbent position. This position is not ideal for managing increased intracranial pressure. The optimal position is to keep the head of the bed elevated at 30 degrees with the neck in a neutral position to promote venous drainage and reduce ICP.

Choice C Reason

Keep the client’s neck in a midline position. This is the correct intervention. Keeping the neck in a midline position helps to ensure proper venous drainage from the brain, thereby reducing intracranial pressure. It is a standard practice in managing patients with elevated ICP.

Choice D Reason

Maintain flexion of the client’s hips at a 90-degree angle. This intervention is incorrect. Flexion of the hips can increase intra-abdominal pressure, which in turn can increase intracranial pressure. It is important to avoid hip flexion in patients with elevated ICP.

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A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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