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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To calculate the number of milliliters (mL) of the hydroxyzine oral suspension to administer, you can use the following formula:
Dose (mL) = Ordered Dose (mg)/ Stock Concentration (mg/mL)
In this case:
- Ordered Dose = 50 mg
- Stock Concentration = 25 mg/5 mL
First, calculate the mg per mL from the stock concentration:
mg per mL = 25 mg/ 5 mL= 5 mg/mL
Now, use the formula to find the mL to administer:
Dose (mL) = 50 mg/ 5 mg/mL = 10 mL
So, the nurse should administer 10 mL of hydroxyzine oral suspension.
Correct Answer is C
Explanation
A. Keep the head of the bed elevated at 15 degrees.
This is not sufficient for preventing aspiration and ensuring proper digestion. The head of the bed should be elevated at least 30 degrees to reduce the risk of aspiration and promote better digestion of enteral feedings.
B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding: It is recommended to change the feeding formula and bag every 24 hours. Placing formula for an extended period can increase the risk of bacterial growth.
C. Flush the tube with 30 ml of water every 4 hr: Regular flushing of the tube helps maintain patency, prevents clogging, and ensures proper hydration. Flushing every 4 hours is a standard practice for continuous feeding.
D. Change the feeding bag and tubing every 72 hr: Feeding bags and tubing should be changed more frequently, typically every 24 hours, to reduce the risk of infection.
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