A nurse is contributing to the plan of care of a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?

Avoid replacing the NG tube if it is accidentally dislodged.

Irrigate the blue pigtail port with sterile saline.

Verify tube placement by injecting air into the larger lumen.

Avoid the nares when providing hygiene care.

Answer and Explanation

The Correct Answer is A

A. Avoid replacing the NG tube if it is accidentally dislodged: After a gastrectomy, improper placement or reinsertion of the NG tube can disrupt the surgical site, leading to complications such as bleeding, leakage, or perforation. If the tube is accidentally dislodged, the nurse should notify the surgeon or provider, as reinsertions in postoperative gastric surgery clients are typically performed under their direction.

B. Irrigate the blue pigtail port with sterile saline: The blue pigtail port (air vent) of a double-lumen NG tube (e.g., Salem sump) should not be irrigated with saline because it functions as an air vent to prevent suction from damaging the stomach lining.

C. Verify tube placement by injecting air into the larger lumen: Injecting air to verify NG tube placement is no longer considered a reliable or evidence-based practice. Placement should be verified by other methods, such as aspiration of gastric contents, pH testing, or radiographic confirmation, especially in postoperative clients.

D. Avoid the nares when providing hygiene care: Hygiene care for the nares is essential to prevent skin breakdown and discomfort in clients with an NG tube. Neglecting the nares could lead to excoriation, pressure injuries, or infection.

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Correct Answer is ["A","B"]

Explanation

A. "I will consume less caffeine and spicy foods."

This statement is correct. Avoiding caffeine and spicy foods can help reduce stomach acid and prevent irritation, which is beneficial for individuals with hiatal hernia.
B. "I will sleep with the head of my bed elevated."

This statement is correct. Elevating the head of the bed can help prevent stomach acid from flowing back into the esophagus while sleeping, reducing symptoms like heartburn.
C. “I will lie down for one-half hour after meals."

This statement is incorrect. It's advisable for individuals with hiatal hernia to remain upright for at least two to three hours after meals to allow gravity to aid digestion and prevent acid reflux.
D. “I will drink less fluid."

This statement is incorrect. Adequate hydration is important for overall health. Drinking water between meals (not during meals) is generally recommended for individuals with hiatal hernia to prevent excess stomach distension during meals.
E. “To gain weight.”

This statement is not directly related to dietary recommendations for hiatal hernia. Weight gain or loss would depend on the individual's overall health goals and is not specific to managing hiatal hernia symptoms.

A. Confirm the client's identity by checking her wristband. B. Provide for the client's privacy by closing the curtains. C. Assist the client into the Sims' position. D. Insert the tip of the enema tubing into the client's rectum.

Correct Answer is A,B,C,D

Explanation

A. Confirm the client's identity by checking her wristband.

B. Provide for the client's privacy by closing the curtains.

C. Assist the client into the Sims' position.

D. Insert the tip of the enema tubing into the client's rectum.

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A nurse is contributing to the plan of care of a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal hernia. Which of the following client statements indicate understanding of the reaching? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

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A nurse is contributing to the plan of care of a client who is postoperative following a gastrectomy and has a double-lumen nasogastric (NG) tube. Which of the following interventions should the nurse include in the plan?

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