The practical nurse (PN) is caring for a client with a nasogastric tube. Which directions should the PN give to the unlicensed assistive personnel (UAP)?
Notify the nurse if the nasogastric tube suction is not working correctly.
Report any change observed in the appearance of the nasogastric drainage.
Clamp the nasogastric tube before giving the client any fluids by mouth.
Irrigate the nasogastric tube with normal saline if the tube becomes obstructed.
The Correct Answer is B
A. Notify the nurse if the nasogastric tube suction is not working correctly: Assessing and troubleshooting suction equipment is a nursing responsibility. The UAP should not be expected to determine suction function or make related judgments.
B. Report any change observed in the appearance of the nasogastric drainage: The UAP can safely observe and report objective changes, such as color, amount, or consistency of drainage, which helps the nurse evaluate the client’s condition.
C. Clamp the nasogastric tube before giving the client any fluids by mouth: Clamping or manipulating the NG tube involves clinical judgment about the client’s readiness for oral intake and tube function, which is beyond the UAP’s role.
D. Irrigate the nasogastric tube with normal saline if the tube becomes obstructed: Irrigation requires sterile technique and assessment of tube patency, which must be performed by a nurse, not delegated to a UAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Order supplies for a dressing change: Obtaining supplies is part of routine postoperative care but is not the first priority. Before any intervention, the PN must ensure the client’s vital functions, airway, breathing, and circulation, are stable.
B. Monitor cardiorespiratory status: Following abdominal surgery, the greatest immediate risk is respiratory compromise due to anesthesia, pain, or immobility. Monitoring the client’s breathing and cardiac function is the first priority to detect hypoxia, respiratory depression, or hemodynamic instability early.
C. Assess the client’s pain level: Pain assessment is important for comfort and to encourage deep breathing and mobility. However, cardiorespiratory monitoring takes precedence, as it ensures life-sustaining stability before addressing discomfort.
D. Provide an incentive spirometer: Promoting lung expansion is beneficial in preventing postoperative atelectasis, but the PN must first confirm adequate respiratory status before instructing or assisting with incentive spirometry.
Correct Answer is A
Explanation
A. Daily weight: Monitoring daily weight is the most accurate way to evaluate fluid balance and the effectiveness of diuretic therapy in heart failure. A gain or loss of more than 2 pounds in 24 hours often indicates fluid retention or loss, directly reflecting how well the medication is controlling edema.
B. Blood pressure readings: Although blood pressure should be monitored to detect potential hypotension from diuretic use, it does not provide the best measure of fluid status. Changes in blood pressure may occur without corresponding changes in total body fluid volume.
C. Color and clarity of urine: Observing urine characteristics offers limited information about diuretic effectiveness. While urine output may increase, the color and clarity do not accurately reflect total fluid balance or the degree of fluid retention in heart failure.
D. Serum electrolytes: Monitoring electrolytes is essential for detecting imbalances caused by diuretic therapy, but it does not directly measure the therapy’s effectiveness in reducing fluid overload. Daily weights remain the most reliable indicator of fluid management success.
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