A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client’s plan of care? (Select all that apply).

Document the color, consistency, and amount of nasogastric drainage.

Encourage hourly use of an incentive spirometer while awake.

Irrigate the nasogastric tube every 4 to 8 hr.

Perform leg exercises every 2 hr.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Documenting the color, consistency, and amount of nasogastric drainage is an important action for the nurse to include in the client’s plan of care. This can help monitor the client’s GI function, ﬂuid balance, and response to treatment. The normal color of nasogastric drainage is clear or yellow-green. Abnormal colors include red, brown, or black, which may indicate bleeding.

Choice B reason: Encouraging hourly use of an incentive spirometer while awake is an important action for the nurse to include in the client’s plan of care. This can help prevent respiratory complications, such as atelectasis and pneumonia, which are common after abdominal surgery. An incentive spirometer is a device that helps the client breathe deeply and expand the lungs.

Choice C reason: Irrigating the nasogastric tube every 4 to 8 hr is not an action that the nurse should include in the client’s plan of care. Routine irrigation of nasogastric tubes is not recommended, as it may increase the risk of infection, tube occlusion, or aspiration. Irrigation should only be done when indicated by specific orders or protocols, or when there is evidence of tube blockage.

Choice D reason: Performing leg exercises every 2 hr is an important action for the nurse to include in the client’s plan of care. This can help prevent venous thromboembolism (VTE), which is a serious complication that can occur after surgery due to immobility and hypercoagulability. Leg exercises can improve blood circulation and reduce stasis in the lower extremities.

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Correct Answer is A

Explanation

Choice A: Maintain the client in Fowler’s position. This is correct because Fowler’s position, which is a semi-sitting position with the head of the bed elevated 45 to 60 degrees, can facilitate the drainage of gastric contents and reduce the risk of aspiration.

Choice B: Use sterile water to irrigate the nasogastric tube. This is incorrect because sterile water is not necessary to irrigate the nasogastric tube, unless the client is immunocompromised or has a high risk of infection. Tap water or normal saline can be used to irrigate the nasogastric tube, following the provider’s orders or the facility’s protocol.

Choice C: Moisten the client’s lips with lemon-glycerin swabs. This is incorrect because lemon-glycerin swabs can dry out and irritate the client’s lips and oral mucosa, especially if used frequently. The nurse should use water-soluble lubricant or lip balm to moisturize the client’s lips and mouth.

Choice D: Measure abdominal girth daily. This is incorrect because measuring abdominal girth daily is not enough to monitor the progression of the intestinal obstruction and the eﬀectiveness of the gastrointestinal decompression. The nurse should measure abdominal girth more frequently, such as every 4 hr or every shift, and report any changes or abnormalities.

A. Provide bulk-forming agent. B. Elevate the head of the bed. C. Measure abdominal girth daily. D. Monitor intake and output every 8 hr.

Correct Answer is B

Explanation

Choice A: Provide bulk-forming agent. This is incorrect because bulk-forming agents are used to treat constipation, not bowel obstruction. They can worsen the obstruction by increasing the stool volume and pressure in the bowel.

Choice B: Elevate the head of the bed. Elevating the head of the bed is an important intervention for clients with a small bowel obstruction. It can help reduce abdominal pressure, promote comfort, and facilitate better respiratory function, especially if the client is experiencing any associated nausea or vomiting. This position can also aid in the proper positioning of the intestines, potentially helping with any non-complicated obstructions.

Choice D: Monitor intake and output every 8 hr. This is incorrect because monitoring intake and output is not enough to assess the ﬂuid and electrolyte balance of a client with a bowel obstruction. The nurse should monitor intake and output more frequently, such as every 4 hr or every shift, and report any signs of dehydration or imbalance.

Choice C: Measure abdominal girth daily. While this is an important assessment for monitoring the status of the obstruction, the immediate intervention of elevating the head of the bed can provide immediate comfort and support during the acute phase of the obstruction.

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A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client’s plan of care? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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