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) Provide instruction on pelvic muscle exercises:
Pelvic muscle exercises are beneficial for urinary incontinence but are not a standard intervention for treating pyelonephritis. Pyelonephritis focuses on managing infection and inflammation of the kidneys rather than strengthening pelvic muscles.

B) Administer skeletal muscle relaxants every 6 hr:
Skeletal muscle relaxants are not typically used in the treatment of pyelonephritis. The focus should be on antibiotics to treat the infection and analgesics for pain relief, rather than muscle relaxants.

C) Encourage fluid intake:
Increasing fluid intake helps flush bacteria from the urinary tract, which can aid in reducing the infection and promoting kidney health. Proper hydration is crucial for clients with pyelonephritis to help manage symptoms and prevent further complications.

D) Monitor vital signs every 8 hr:
While monitoring vital signs is important, it should be done more frequently than every 8 hours, especially in the acute phase of pyelonephritis, to promptly identify any signs of worsening infection or sepsis.

A. "I should limit my weightlifting to three times per week." B. "I can continue to horseback ride." C. "I will go walking with a friend around our neighborhood." D. "I will join my brother at his community aerobics class."

Correct Answer is C

Explanation

A) "I should limit my weightlifting to three times per week.": While weightlifting can be beneficial for bone health, it is generally recommended to engage in weight-bearing and resistance exercises more frequently than three times a week for optimal bone density. The frequency and type of weightlifting should be tailored to individual needs and safety considerations.

B) "I can continue to horseback ride.": Horseback riding, especially if not done carefully, poses a risk of falls and fractures, which can be dangerous for individuals with osteoporosis. Activities with a higher risk of injury should be avoided or approached with caution.

C) "I will go walking with a friend around our neighborhood.": Walking is a low-impact, weight-bearing exercise that promotes bone health and mobility without high risk. It is a suitable and recommended activity for individuals with osteoporosis to help maintain bone density and prevent falls.

D) "I will join my brother at his community aerobics class.": Aerobics classes may involve high-impact exercises and movements that could increase the risk of fractures or falls in individuals with osteoporosis. Low-impact, bone-strengthening activities are generally recommended instead.

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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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