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 A

Explanation

Choice A reason: This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.

Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

A. To ambulate without discomfort. B. To avoid pain-causing activity. C. To show evidence of incision healing. D. To take analgesics as prescribed.

Correct Answer is A

Explanation

Choice A Reason: This is correct because it reflects a measurable and realistic goal that addresses the client's problem of activity intolerance related to pain. Ambulation promotes circulation, prevents complications, and enhances recovery.

Choice B Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Avoiding pain-causing activity may lead to immobility and further complications.

Choice C Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Incision healing is an expected outcome of wound care, not activity.

Choice D Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Taking analgesics as prescribed may help relieve pain, but it does not promote activity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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