A patient with a nasogastric (NG) tube in place is experiencing respiratory distress. What is the most appropriate initial nursing intervention?
Elevate the head of the bed to 90 degrees
Administer a bronchodilator as prescribed.
Check the placement of the NG tube to ensure it has not dislodged into the lungs.
Increase the flow rate of the patient’s oxygen therapy.
The Correct Answer is C
A. Elevate the head of the bed to 90 degrees: While elevating the head of the bed may help ease breathing, it does not address the potential issue of NG tube misplacement.
B. Administer a bronchodilator as prescribed: This would only be appropriate if the patient’s respiratory distress were related to bronchospasm or asthma, not NG tube displacement.
C. Check the placement of the NG tube to ensure it has not dislodged into the lungs. When a patient with an NG tube experiences respiratory distress, the tube may have dislodged and entered the respiratory tract, which could obstruct breathing. Verifying the placement of the NG tube is critical to preventing aspiration or further complications.
D. Increase the flow rate of the patient’s oxygen therapy: This may provide temporary relief but does not resolve the underlying cause of the distress if the NG tube has entered the respiratory tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The glomerular filtration rate decreases because inflammatory cells invade the already damaged kidneys: Inflammation is not the primary mechanism of decreased GFR in ATN. It is more related to cellular damage and dysfunction.
B. The glomerular filtration rate decreases because there is a reduction of blood flow to the kidneys: While reduced blood flow can contribute to acute kidney injury, the ongoing decline in GFR in ATN is due to tubular damage, not ongoing ischemia.
C. The glomerular filtration rate decreases because there is obstruction leading to the filtration system backing up and eventually shutting the kidneys down: Obstruction is not the key issue in ATN; rather, it’s the tubular cell injury that disrupts filtration.
D. The glomerular filtration rate decreases because there is injury to the renal tubular cells. Acute tubular necrosis (ATN) involves damage to the renal tubular cells, which disrupts the ability of the nephrons to filter blood efficiently. This cellular injury is the primary cause of the decline in glomerular filtration rate (GFR) in ATN.
Correct Answer is B
Explanation
A. "Vomiting blood or material that looks like coffee grounds is a serious sign that I need to go to the emergency room." This is a correct understanding. Vomiting blood or coffee-ground material is a sign of gastrointestinal bleeding and requires immediate medical attention.
B. "If I experience severe abdominal pain, I should take an over-the-counter antacid and rest."
Taking an over-the-counter antacid without contacting a healthcare provider for severe pain could mask serious complications, such as recurrent bleeding or perforation, that need immediate medical attention. This statement indicates a need for further teaching.
C. "I should avoid taking NSAIDs like ibuprofen as they can increase my risk of bleeding." This is a correct understanding, as NSAIDs can cause or worsen gastric ulcers and increase the risk of bleeding.
D. "I should immediately report any black, tarry stools to my healthcare provider."This is a correct understanding. Black, tarry stools (melena) indicate upper gastrointestinal bleeding.
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