A nurse is caring for a client who has an NG tube due to an intestinal obstruction. Using the nursing process for clinical decision making, which of the following actions should the nurse take to maintain NG patency?
Place the client on his right side if tube resistance occurs.
Check the tube patency every 4 hr.
Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr.
Maintain the client in a supine position.
The Correct Answer is B
A) Place the client on his right side if tube resistance occurs: Positioning the client on the right side can help facilitate gastric emptying, but it is not a primary action to ensure NG tube patency. If tube resistance occurs, the nurse should assess and address the resistance more directly.
B) Check the tube patency every 4 hr: Regularly checking the tube patency ensures that the NG tube remains open and functional, preventing blockages and ensuring continuous decompression or feeding as required.
C) Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr: Flushing the tube helps maintain patency, but the amount and frequency may vary based on facility protocols. Flushing every 8 hours might not be frequent enough to prevent blockages.
D) Maintain the client in a supine position: Keeping the client in a supine position is not recommended for maintaining NG tube patency and may increase the risk of aspiration. A semi-Fowler's position is usually preferred to promote drainage and reduce aspiration risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Drowsiness: While drowsiness can be a symptom of elevated magnesium levels, it is not the most critical finding to report immediately. Drowsiness can be observed with other conditions as well.
B) Diminished patellar reflexes: This can be indicative of hypermagnesemia, but it is a less immediate concern compared to other symptoms. Monitoring reflexes is important, but not the priority.
C) Generalized muscle weakness: Muscle weakness is a common symptom of elevated magnesium levels, but it is less urgent compared to cardiac issues. Although important, it does not pose an immediate risk like bradycardia.
D) Bradycardia: Elevated magnesium levels can cause serious cardiac complications, including bradycardia. This can be life-threatening and requires prompt attention to prevent severe outcomes, making it the priority to report to the provider.
Correct Answer is C
Explanation
A) "I should make sure that most of my meals contain fried foods to maintain my calorie count": Fried foods are generally high in fat and can be difficult to digest, particularly for individuals with malabsorption syndrome. They are not recommended as a primary source of calories due to their potential to exacerbate gastrointestinal symptoms.
B) "I should change to a gluten-free diet to rest my bowel": A gluten-free diet is beneficial for individuals with celiac disease, but it is not universally required for all inflammatory bowel diseases. The decision to adopt a gluten-free diet should be based on specific medical advice rather than general guidelines for inflammatory bowel disease.
C) "I should try to limit foods containing lactose to prevent bloating and cramping": Limiting lactose-containing foods is a common recommendation for individuals with malabsorption syndrome, especially if lactose intolerance is present. Lactose can exacerbate bloating and cramping, so managing intake can help alleviate these symptoms.
D) "I should eat a high-fiber diet daily to decrease my episodes of flare-ups": High-fiber diets are not always recommended for individuals with inflammatory bowel disease, as fiber can exacerbate symptoms and contribute to flare-ups. A low-fiber or modified fiber diet may be more appropriate depending on the individual’s symptoms and disease state.
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