A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?
To administer medications and electrolytes
To dilate the stomach as a presurgical preparation
You will not be able to eat for several days
To remove secretions and decompress your stomach
The Correct Answer is D
Choice A Reason: This is incorrect because administering medications and electrolytes is not the primary purpose of inserting a nasogastric tube for a client with acute peritonitis. Medications and electrolytes can be given through other routes, such as IV or oral.
Choice B Reason: This is incorrect because dilating the stomach as a presurgical preparation is not a relevant Reason for inserting a nasogastric tube for a client with acute peritonitis. Dilating the stomach may be done before some types of gastric surgery, but it does not apply to peritonitis.
Choice C Reason: This is incorrect because stating that you will not be able to eat for several days is not an adequate explanation for inserting a nasogastric tube for a client with acute peritonitis. This statement does not address the rationale or the benefits of the procedure. It may also cause anxiety and resentment in the client.
Choice D Reason: This is the correct choice because removing secretions and decompressing the stomach is the main Reason for inserting a nasogastric tube for a client with acute peritonitis. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can cause abdominal distension, pain, nausea, and vomiting. A nasogastric tube can suction out the gastric contents and reduce the pressure and irritation in the abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A Reason: This choice is incorrect. Placing the client into a supine position is not an action that the nurse should take, as it can compromise the airway and increase the risk of aspiration. The nurse should position the client on their side with their head tilted slightly forward to allow saliva and secretions to drain out of their mouth.
Choice B Reason: This choice is incorrect. Applying restraints is not an action that the nurse should take, as it can cause injury and increase agitation. The nurse should protect the client from harm by removing any objects or furniture that may cause harm and padding any hard surfaces with blankets or pillows.
Choice C Reason: This choice is incorrect. Inserting a bite stick into the client's mouth is not an action that the nurse should take, as it can cause injury and obstruction. The nurse should never force anything into the client's mouth during a seizure, as it can damage their teeth, gums, tongue, or jaw.
Choice D Reason: This is a correct choice. Loosening restrictive clothing is an action that the nurse should take, as it can improve breathing and circulation. The nurse should unbutton any tight collars, belts, or ties that may constrict the chest or neck.
Choice E Reason: This is a correct choice. Placing a pillow under the client's head is an action that the nurse should take, as it can prevent injury and provide comfort. The nurse should support the client's head with a soft pillow or cushion to prevent hitting it against any hard surfaces.
Correct Answer is B
Explanation
Choice A Reason: The test is not inconclusive, but rather positive for conductive hearing loss. The Weber test involves placing a vibrating tuning fork on the center of the forehead and asking the client which ear hears the sound louder. It can help differentiate between conductive and sensorineural hearing loss.
Choice B Reason: This is the correct choice. The client has conductive hearing loss, which is a type of hearing loss that occurs when sound waves are blocked or reduced in the outer or middle ear. It can be caused by earwax, infection, fluid, perforation, or trauma. In conductive hearing loss, the Weber test shows lateralization to the affected ear, meaning the sound is heard louder in that ear.
Choice C Reason: The client does not have normal hearing, but rather conductive hearing loss. In normal hearing, the Weber test shows no lateralization, meaning the sound is heard equally in both ears.
Choice D Reason: The client does not have sensorineural hearing loss, but rather conductive hearing loss. Sensorineural hearing loss is a type of hearing loss that occurs when there is damage to the inner ear or auditory nerve. It can be caused by aging, noise exposure, disease, or drugs. In sensorineural hearing loss, the Weber test shows lateralization to the unaffected ear, meaning the sound is heard louder in that ear.
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