A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

Instill 50 mL of normal saline solution into the tube and clamp the tube for one hour.

Turn the suction off while allowing the client to rinse his mouth with cool water.

Provide oral sponge toothettes so the client can cleanse and moisten his mouth.

Teach the client that the oral mucosa must remain dry to prevent aspiration.

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because instilling normal saline solution into the nasogastric tube can cause fluid overload, electrolyte imbalance, or aspiration. Clamping the tube for one hour can also increase the risk of aspiration and gastric distension.

Choice B Reason: This is incorrect because turning the suction off can cause gastric distension and discomfort. Rinsing the mouth with cool water can also increase the risk of aspiration if the client swallows some of the water.

Choice C Reason: This is correct because oral sponge toothettes are soft and gentle on the oral mucosa and can help moisten and cleanse the mouth without causing irritation or aspiration.

Choice D Reason: This is incorrect because teaching the client that the oral mucosa must remain dry is false and can lead to further dryness, cracking, bleeding, and infection. The oral mucosa should be kept moist and clean to prevent these complications.

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Correct Answer is ["B"]

Explanation

Choice A Reason: This is incorrect because nociceptive pain is caused by stimulation of nociceptors, which are sensory receptors that respond to tissue damage or inflammation. Nociceptive pain is usually localized and throbbing or aching.

Choice B Reason: This is correct because neuropathic pain is caused by damage or dysfunction of the nervous system. Neuropathic pain is usually diffuse and burning or shooting.

Choice C Reason: This is incorrect because acute pain is defined by its duration rather than its cause or quality. Acute pain lasts less than six months and usually has an identifiable cause and predictable course.

Choice D Reason: This is incorrect because visceral pain is caused by stimulation of nociceptors in the internal organs. Visceral pain is usually deep and cramping or squeezing.

A. Notify the healthcare provider. B. Document the event on the chart. C. Complete an incident report. D. Inform the nurse on the next shift.

Correct Answer is A

Explanation

Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.

Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.

Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.

Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.

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A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

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