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 D

Explanation

Choice A: Place the client on his back. This is incorrect because the client should be placed in a sitting position with the head of the bed elevated to 30 to 45 degrees. This allows the ﬂuid to accumulate in the lower abdomen and reduces the risk of puncturing the diaphragm.

Choice B: Have the client increase ﬂuid intake after the procedure. This is also incorrect because the client should restrict ﬂuid intake after the procedure to prevent ﬂuid overload and electrolyte imbalance. The nurse should monitor the client’s intake and output, weight, and vital signs.

Choice C: Assure the client that the procedure is painless. This is not true because the client may experience some discomfort or pressure during the insertion of the needle or catheter. The nurse should administer analgesics as prescribed and provide emotional support.

Choice D: Instruct the client to empty his bladder. This is correct because this reduces the risk of bladder injury during the procedure. The nurse should also measure and record the amount of urine voided.

A. “Both illnesses result in malabsorption of nutrients.” B. “Both illnesses begin in the rectum.” C. “Both illnesses manifest fistula formation.” D. “Both illnesses are inﬂammatory in nature.”

Correct Answer is D

Explanation

Choice A: Both illnesses result in malabsorption of nutrients. This is incorrect because malabsorption of nutrients is more common in Crohn’s disease than in ulcerative colitis. Crohn’s disease can aﬀect any part of the gastrointestinal tract, including the small intestine, where most of the nutrient absorption occurs. Ulcerative colitis mainly aﬀects the colon and rectum, which are responsible for water and electrolyte absorption.

Choice B: Both illnesses begin in the rectum. This is incorrect because ulcerative colitis usually begins in the rectum and spreads proximally to the colon, while Crohn’s disease can begin anywhere in the gastrointestinal tract, from the mouth to the anus.

Choice C: Both illnesses manifest fistula formation. This is incorrect because fistula formation is more common in Crohn’s disease than in ulcerative colitis. Fistulas are abnormal connections between diﬀerent parts of the gastrointestinal tract or other organs, such as the bladder, vagina, or skin. They are caused by inﬂammation, ulceration, and infection that penetrate through the bowel wall.

Choice D: Both illnesses are inﬂammatory in nature. This is correct because both ulcerative colitis and Crohn’s disease are types of inﬂammatory bowel disease (IBD), which are chronic conditions that cause inﬂammation and damage to the gastrointestinal tract. The exact cause of IBD is unknown, but it may involve genetic, immune, environmental, and microbial factors.

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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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