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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "The client is preoccupied with a supposed body defect.": This manifestation is more characteristic of body dysmorphic disorder rather than generalized anxiety disorder (GAD).

B. "The client compulsively bites fingernails.": Nail-biting is often associated with obsessive-compulsive disorder (OCD) or other stress-related behaviors rather than GAD.

C. "The client exhibits hoarding behaviors.": Hoarding is typically associated with obsessive-compulsive disorder (OCD) and not generalized anxiety disorder.

D. "The client puts off making decisions.": Individuals with generalized anxiety disorder often experience indecisiveness and procrastination due to excessive worry and fear of making the wrong choice. This is a common manifestation of GAD

A. "I have been taking acetaminophen when my knees start to hurt." B. "I've been sleeping on my back with a large pillow under my knees." C. "I have been exercising every day, even when I have pain." D. "I've been changing my lidocaine patches every 18 hours."

Correct Answer is A

Explanation

A) "I have been taking acetaminophen when my knees start to hurt.":
Taking acetaminophen for pain relief indicates that the client is managing the osteoarthritis symptoms appropriately. Acetaminophen is a recommended first-line treatment for mild to moderate pain associated with osteoarthritis and can help improve the client's quality of life by reducing discomfort.

B) "I've been sleeping on my back with a large pillow under my knees.":
Sleeping with a large pillow under the knees can cause the knees to remain in a flexed position for prolonged periods, potentially leading to joint stiffness and worsening pain. This practice is not typically recommended for clients with osteoarthritis as it can exacerbate symptoms.

C) "I have been exercising every day, even when I have pain.":
While regular exercise is beneficial for managing osteoarthritis, it is important to avoid exercising through significant pain. Pain during exercise may indicate overuse or joint damage. Clients should be encouraged to modify their activities to prevent further joint stress and manage symptoms effectively.

D) "I've been changing my lidocaine patches every 18 hours.":
Lidocaine patches are typically designed for 12-hour application periods, followed by a 12-hour off period. Changing the patches every 18 hours may not provide the intended relief and could lead to inconsistent pain management. Proper use of pain management techniques is essential for effective disease management.

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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?

Nursing Test Bank

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