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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Overdose: The patient has ingested a large quantity of unknown pills, leading to severe metabolic acidosis, high anion gap, and possible toxic accumulation. Dialysis is often indicated to clear toxins in the case of overdose, especially if renal function is impaired (as indicated by elevated creatinine).

B. Chronic Kidney Disease: While chronic kidney disease may eventually require dialysis, the acute overdose and metabolic acidosis are the more immediate concerns requiring urgent dialysis.

C. Hypertension: Hypertension may require management, but it is not the primary reason to initiate urgent dialysis in this scenario. The overdose and metabolic acidosis take precedence.

D. Dehydration: Dehydration alone does not necessitate dialysis. However, the overdose, metabolic acidosis, and renal impairment are the critical reasons for initiating dialysis.

A. Flush the T-tube with sterile water every 6 hours to maintain patency. B. Clamp the T-tube for 12 hours each day to reduce bile flow C. Secure the T-tube to the patient's gown to prevent accidental dislodgement. D. Maintain the drainage bag below the level of the abdomen to promote gravity drainage.

Correct Answer is D

Explanation

A. Flush the T-tube with sterile water every 6 hours to maintain patency: T-tubes are generally not flushed unless prescribed by a healthcare provider because flushing can introduce bacteria and cause complications. Patency is typically maintained by gravity drainage alone.

B. Clamp the T-tube for 12 hours each day to reduce bile flow: Clamping the T-tube is not routinely recommended for such long periods unless directed by the healthcare provider. Clamping is usually done gradually, often for 1-2 hours, to assess the patient’s ability to tolerate bile drainage naturally before tube removal.

C. Secure the T-tube to the patient's gown to prevent accidental dislodgement: While securing the T-tube prevents accidental dislodgement, the tube should be taped to the skin rather than the gown, as attaching it to clothing can increase the risk of unintentional dislodgement with movement.

D. Maintain the drainage bag below the level of the abdomen to promote gravity drainage. This is the correct answer because positioning the drainage bag below the abdomen allows for gravity to assist in the flow of bile from the bile duct, preventing backup and promoting proper drainage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A patient with a nasogastric (NG) tube in place is experiencing respiratory distress. What is the most appropriate initial nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A patient is recovering from a common bile duct exploration and has a T-tube drain in place. As the nurse, which action is most appropriate to ensure proper function and patient safety?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

A patient with acute pancreatitis is being discharged from the hospital. Which statement made by the patient indicates a need for further teaching regarding their discharge instructions?

A nurse practicing population health works for a local hospital's weight-loss program for bariatric patients. After assisting to implement various health-style changes in their care plans, which of the following findings would indicate to the nurse that the interventions are working?

A patient with a nasogastric (NG) tube in place is experiencing respiratory distress. What is the most appropriate initial nursing intervention?

During the process of collecting a comprehensive medical history from a client who has been admitted with pyelonephritis, which of the following symptoms or historical details would the nurse most likely expect the client to report?

A nurse is gathering data on a client who was admitted with pyelonephritis. Which of the following manifestations should the nurse expect the client to be exhibiting? (Select All that Apply.)

A nurse is providing education to a client who has recently been diagnosed with Crohn's disease. Which of the following explanations by the nurse best simplifies and explains the disorder in non-medical terms?