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 B
Explanation
A) It manifests as a sense of relief upon the loved one's death: This describes a possible outcome of anticipatory grief but does not define anticipatory grief itself. While relief can be a reaction, it is not the core characteristic of anticipatory grief.
B) It causes a prolonged grief response to occur: Anticipatory grief involves experiencing grief before the actual loss occurs. This process can sometimes lead to a prolonged grief response, as individuals might go through stages of grief before and after the loss.
C) It occurs when the loss of a loved one cannot be shared openly: This describes disenfranchised grief, which happens when the loss is not socially acknowledged or supported. Anticipatory grief occurs prior to the loss, not due to a lack of social support.
D) It remains difficult to process due to a lack of finality: While anticipatory grief can be challenging due to ongoing uncertainties and emotional strain, it is not primarily defined by a lack of finality. The grief occurs as individuals anticipate the impending loss.
Correct Answer is B
Explanation
A) Provide a detailed account of the feelings and sounds the client will experience:
While explaining the procedure can be helpful, it might increase anxiety for someone with claustrophobia by focusing on potentially distressing details. It's more effective to use relaxation techniques or medications to manage acute anxiety.
B) Obtain a prescription for clonazepam:
Clonazepam, a benzodiazepine, can help reduce anxiety and is often used to manage claustrophobia during procedures like an MRI. This medication can help the client stay calm and more comfortable during the scan.
C) Obtain a prescription for ziprasidone:
Ziprasidone is an antipsychotic medication and is not typically used for managing situational anxiety or claustrophobia. Using an appropriate anxiolytic like clonazepam is more effective in this context.
D) Inform the client that the time spent in the MRI machine will only be 5 min:
This statement is misleading as MRI scans usually take longer than 5 minutes. Providing inaccurate information can undermine trust and increase anxiety if the procedure takes longer than stated.
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