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.

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 C

Explanation

Choice A Reason: This is incorrect because abdominal girth can indicate the presence of fecal impaction, but it does not reflect the client's hemodynamic status or potential complications of the procedure.

Choice B Reason: This is incorrect because bowel sounds can indicate the level of bowel motility, but they do not provide information about the client's cardiovascular or respiratory function.

Choice C Reason: This is correct because vital signs can indicate the client's baseline condition and any changes during or after the procedure. Digital removal of a fecal impaction can stimulate the vagus nerve and cause bradycardia, hypotension, or cardiac arrest.

Choice D Reason: This is incorrect because breath sounds can indicate the client's respiratory status, but they are not directly affected by the procedure. However, breath sounds should be monitored for signs of aspiration if the client receives sedation or analgesia.

A. Begin with questions that are less sensitive in nature. B. Ask questions in a vague, non-specific format. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.

Correct Answer is A

Explanation

Choice A Reason: This is correct because beginning with questions that are less sensitive in nature can help establish rapport and trust with the client, and make the client more comfortable and willing to disclose personal information.

Choice B Reason: This is incorrect because asking questions in a vague, non-specific format can confuse the client and lead to inaccurate or incomplete data. The nurse should ask clear, direct, and open-ended questions that elicit relevant information.

Choice C Reason: This is incorrect because getting the most difficult questions over with first can make the client feel anxious, embarrassed, or defensive, and discourage further communication. The nurse should build up to the more sensitive questions gradually and respectfully.

Choice D Reason: This is incorrect because sharing personal values to put the client at ease can be inappropriate and unprofessional, as it may impose the nurse's beliefs or opinions on the client or create bias or judgment. The nurse should maintain a neutral and objective attitude and respect the client's values.

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 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

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Correct Answer is C

Explanation

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

Correct Answer is A

Explanation

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? (Select all that apply.)

The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Which equipment should the nurse use to measure a 5 mL dose of viscous liquid solution most accurately to be administered orally?