The nurse is caring for a client who has been NPO for 5 days with a nasogastric tube to suction. What nursing intervention takes priority?
Request daily x-ray order for tube placement
Measure the gastric output every 2 hours
Maintain fluid and electrolyte balance
Eliminate discomfort from the tube
The Correct Answer is C
A. Request daily x-ray order for tube placement: Ensuring proper nasogastric tube placement is essential for patient safety to prevent aspiration. However, after initial verification and routine checks (e.g., pH testing, tube marking), daily X-rays are not typically required unless there is concern for displacement. While important, this is not the highest priority in a patient NPO for 5 days.
B. Measure the gastric output every 2 hours: Monitoring gastric output helps track fluid loss and informs electrolyte management. Although frequent measurement is important, it is part of supporting fluid and electrolyte balance rather than the primary priority itself.
C. Maintain fluid and electrolyte balance: NPO status with continuous nasogastric suction places the client at high risk for significant fluid and electrolyte imbalances, like hypokalemia, hyponatremia, and metabolic alkalosis. Maintaining homeostasis is critical because disturbances can lead to life-threatening complications like cardiac arrhythmias, hypotension, or neurologic changes.
D. Eliminate discomfort from the tube: Addressing discomfort improves client comfort and compliance but does not address the immediate physiologic risks associated with prolonged NPO status and continuous suctioning. Comfort measures are important but secondary to maintaining fluid and electrolyte balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Having another nurse assist to perform the bed bath: Assistance may be necessary for safety and efficiency, especially with immobile clients, but it does not inherently convey emotional presence or therapeutic communication. The focus is on task completion rather than directly expressing caring behaviors to the client.
B. Making sure that daily hygiene was completed on time: Timeliness reflects organization and adherence to routine care, but it does not address the interpersonal aspect of nursing. Completing hygiene on schedule ensures physical care needs are met but does not demonstrate compassion or emotional connection.
C. Speaking in a calm voice and using gentle touch: Even in a comatose state, patients may retain some level of sensory perception, particularly auditory and tactile awareness. Calm verbal communication and gentle touch promote dignity, reduce potential stress responses, and reflect holistic, patient-centered care that acknowledges the client’s humanity despite unconsciousness.
D. Maintaining eye contact with the client throughout: Eye contact is a valuable communication tool for conscious patients, but in a comatose client, it does not provide meaningful interaction. Since the client cannot visually engage, this action does not effectively convey caring compared to auditory and tactile approaches.
Correct Answer is A
Explanation
A. 72 hours: Renal compensation for respiratory acidosis involves the kidneys increasing bicarbonate (HCO₃⁻) reabsorption and excreting hydrogen ions (H⁺) to buffer excess carbon dioxide. This process is relatively slow because it relies on tubular transport mechanisms and enzymatic activity within the nephron. Renal compensation occur over 2–3 days, with near-maximal compensation around 72 hours after the onset of the respiratory disturbance.
B. 10 days: A period of 10 days is far longer than necessary for renal compensation. While full stabilization and chronic adaptations may continue beyond 72 hours in persistent respiratory acidosis, the initial compensatory response sufficient to partially normalize pH generally occurs within 2–3 days, making 10 days unnecessarily prolonged.
C. 4 hours: Four hours is insufficient for renal compensation to significantly affect blood pH. While respiratory changes can alter pH almost immediately through CO₂ retention or elimination, renal mechanisms require time for tubular cells to adjust bicarbonate reabsorption and hydrogen ion excretion.
D. 8 hours: Eight hours is still too short for effective renal compensation. Early changes may occur in tubular activity, but detectable changes in arterial pH are not expected until several days after the onset of respiratory acidosis. Initial buffering is primarily handled by extracellular and intracellular chemical buffers, not renal compensation.
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