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 C

Explanation

A) Sensorineural deafness
This is a possible complication of mumps but not a symptom indicating the illness stage. It can occur after the infection and does not reflect the active phase of the disease.

B) Maculopapular rash
This type of rash is not typically associated with mumps. It may indicate other viral infections, such as measles or rubella, rather than mumps.

C) Swelling of the parotid glands
Swelling of the parotid glands is a hallmark symptom of the illness stage of mumps. This swelling typically appears a few days after the onset of other symptoms like fever and malaise and signifies the active phase of the infection.

D) Nuchal rigidity
Nuchal rigidity can occur if there is mumps-related meningitis, but it is not a typical sign of the initial illness stage. It indicates potential complications involving the central nervous system.

A. Decrease folic acid intake. B. Increase lactose intake. C. Provide a gluten-free diet. D. Provide a low-fat diet.

Correct Answer is D

Explanation

A) Decrease folic acid intake: Decreasing folic acid intake is not advisable for clients with malabsorption syndrome. In fact, clients with malabsorption often require increased folic acid due to poor absorption of nutrients, especially in conditions like celiac disease or other causes of malabsorption.

B) Increase lactose intake: Increasing lactose intake is not appropriate for clients with malabsorption syndrome, particularly if they have lactose intolerance. Lactose can exacerbate symptoms such as diarrhea and steatorrhea in these clients.

C) Provide a gluten-free diet: A gluten-free diet is crucial for clients with celiac disease, which is a type of malabsorption syndrome. However, if the malabsorption syndrome is due to another cause, a gluten-free diet might not address the issue. The focus should be on managing fat intake to reduce steatorrhea.

D) Provide a low-fat diet: A low-fat diet is the most appropriate intervention for managing severe steatorrhea, which is the presence of excess fat in the stool. Reducing fat intake helps to minimize fat malabsorption and the associated symptoms, providing relief from steatorrhea.

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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?

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