A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

Maintain the client in Fowler’s position.

Use sterile water to irrigate the nasogastric tube.

Moisten the client’s lips with lemon-glycerin swabs.

Measure abdominal girth daily.

Answer and Explanation

The Correct Answer is A

Choice A: Maintain the client in Fowler’s position. This is correct because Fowler’s position, which is a semi-sitting position with the head of the bed elevated 45 to 60 degrees, can facilitate the drainage of gastric contents and reduce the risk of aspiration.

Choice B: Use sterile water to irrigate the nasogastric tube. This is incorrect because sterile water is not necessary to irrigate the nasogastric tube, unless the client is immunocompromised or has a high risk of infection. Tap water or normal saline can be used to irrigate the nasogastric tube, following the provider’s orders or the facility’s protocol.

Choice C: Moisten the client’s lips with lemon-glycerin swabs. This is incorrect because lemon-glycerin swabs can dry out and irritate the client’s lips and oral mucosa, especially if used frequently. The nurse should use water-soluble lubricant or lip balm to moisturize the client’s lips and mouth.

Choice D: Measure abdominal girth daily. This is incorrect because measuring abdominal girth daily is not enough to monitor the progression of the intestinal obstruction and the eﬀectiveness of the gastrointestinal decompression. The nurse should measure abdominal girth more frequently, such as every 4 hr or every shift, and report any changes or abnormalities.

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Correct Answer is C

Explanation

Choice A: Ketoacidosis. This is incorrect because ketoacidosis is a complication of hyperglycemia, not hypoglycemia. Ketoacidosis occurs when the body breaks down fat for energy due to insufficient insulin, resulting in the accumulation of ketones and acids in the blood. Ketoacidosis can cause symptoms such as nausea, vomiting, abdominal pain, fruity breath odor, deep and rapid breathing, and altered mental status.

Choice B: Hyperglycemia. This is incorrect because hyperglycemia is a condition of high blood glucose, not low blood glucose. Hyperglycemia can occur due to insufficient insulin, excessive carbohydrate intake, infection, stress, or illness. Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, blurred vision, fatigue, and headache.

Choice C: Hypoglycemia. This is correct because hypoglycemia is a condition of low blood glucose, which can occur due to excessive insulin, inadequate carbohydrate intake, exercise, alcohol consumption, or medication interactions. Hypoglycemia can cause symptoms such as sweating, tachycardia, palpitations, tremors, hunger, anxiety, confusion, dizziness, weakness, and seizures.

Choice D: Nephropathy. This is incorrect because nephropathy is a complication of chronic hyperglycemia, not acute hypoglycemia. Nephropathy is a kidney disease that results from damage to the small blood vessels and glomeruli in the kidneys due to high blood glucose levels. Nephropathy can cause symptoms such as proteinuria, edema, hypertension, and renal failure.

A. "Insulin injected into the thigh is the most rapidly absorbed." B. "I should shake the botle of insulin before withdrawing the medication." C. "I will use Lantus insulin immediately before each meal." D. "Unopened vials of insulin should be kept in my refrigerator."

Correct Answer is D

Explanation

Choice A reason: Insulin injected into the thigh is not the most rapidly absorbed. The abdomen is the preferred site for insulin injection, as it has the fastest and most consistent absorption rate. The thigh, arm, and butock have slower and more variable absorption rates12.

Choice B reason: The botle of insulin should not be shaken before withdrawing the medication. Shaking can damage the insulin molecules and aﬀect their potency and eﬀectiveness. Instead, the botle should be gently rolled between the palms to mix the insulin evenly13.

Choice C reason: Lantus insulin should not be used immediately before each meal. Lantus is a long-acting insulin that provides a steady basal level of insulin for 24 hours. It should be taken once a day at the same time every day, regardless of meals. Humalog is a rapid-acting insulin that can be used immediately before each meal to cover the postprandial glucose spikes14.

Choice D reason: Unopened vials of insulin should be kept in the refrigerator until needed. This can help preserve their quality and potency until their expiration date. Opened vials of insulin can be kept at room temperature for up to 28 days, depending on the type and brand

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A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

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