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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Roast chicken with white rice is a low-fiber, easy-to-digest meal that is suitable for a client who has recovered from the acute phase of diverticulitis. A low-fiber diet can help reduce the stress on the colon and allow it to heal. White rice is a refined grain that has less fiber than whole grains, such as brown rice or quinoa12.
Choice B reason: A poached egg with sliced tomatoes is not a good choice for a client who has recovered from the acute phase of diverticulitis. Although eggs are a good source of protein and do not contain fiber, tomatoes are high in fiber and may irritate the colon. Tomatoes also have seeds, which were previously thought to cause problems for people with diverticular disease, but there is no evidence to support this. However, some people may still find them uncomfortable to eat13.
Choice C reason: Bean soup with steamed broccoli is not a good choice for a client who has recovered from the acute phase of diverticulitis. Beans and broccoli are both high in fiber and may cause gas, bloating, and cramping in the colon. A high-fiber diet is recommended for people with diverticulosis (the presence of pouches without inflammation) to prevent constipation and diverticulitis, but it should be avoided during or shortly after an episode of diverticulitis12.
Choice D reason: Ham sandwich on white bread is not a good choice for a client who has recovered from the acute phase of diverticulitis. Although white bread is low in fiber, ham is a processed meat that may increase the risk of developing diverticular disease. Research suggests that a diet high in red meat and processed meat may contribute to inflammation and infection of the pouches in the colon.
Correct Answer is B
Explanation
Choice A: Weigh the client weekly. This is incorrect because the client receiving PN should be weighed daily, not weekly, to monitor fluid balance and nutritional status. The nurse should also measure the client’s intake and output, blood glucose, electrolytes, and other laboratory values daily.
Choice B: Reduce the rate of the solution gradually to discontinue. This is correct because the nurse should taper off the PN solution slowly to prevent rebound hypoglycemia, which can occur when the high concentration of glucose in the PN solution is abruptly stopped. The nurse should follow the provider’s orders or the facility’s protocol for reducing and discontinuing PN.
Choice C: Remove solution from refrigerator 2 hr before infusion. This is incorrect because the nurse should remove the PN solution from the refrigerator 30 to 60 minutes before infusion, not 2 hr, to allow it to reach room temperature. Infusing a cold solution can cause discomfort, vasoconstriction, and impaired absorption of nutrients.
Choice D: Shake the solution before hanging if there is a layer of fat present on the top. This is incorrect because the nurse should not shake the PN solution at all, as this can cause fat emulsion droplets to coalesce and form large particles that can clog the filter or cause embolism. The nurse should gently invert or roll the PN solution container to mix it if there is any separation of components.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.