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 B

A. Avoid replacing the NG tube if it is accidentally dislodged: If the NG tube is accidentally dislodged, it should be replaced to maintain gastric decompression unless contraindicated. This option is incorrect.
B. Irrigate the blue pigtail port with sterile saline.

This is the correct answer. In a double-lumen nasogastric (NG) tube, one lumen (usually blue) is used for gastric decompression (removal of gastric contents), and the other lumen (usually white) is used for air venting and irrigation. Irrigating the blue pigtail port with sterile saline is part of the nursing care to maintain tube patency and prevent blockage.
C. Verify tube placement by injecting air into the larger lumen: Tube placement verification is typically done by auscultating for air while injecting air into the smaller lumen (air venting and irrigation lumen), not the larger lumen. Injecting air into the larger lumen does not serve this purpose and can be dangerous. This option is incorrect.

D. Avoid the nares when providing hygiene care: Proper hygiene care around the nares is essential to prevent irritation and breakdown of the skin. However, this option does not specifically address the care of the NG tube itself. This option is incorrect.

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Correct Answer is B

Explanation

A. Blood glucose 150 mg/dL:
This blood glucose level is slightly elevated but not significantly concerning on its own. It may be related to stress or other factors. In the context of acute gastroenteritis, it might be secondary to dehydration, but it is not an immediate priority unless the client is diabetic.

B. Potassium 2.5 mEq/L:
This is the correct answer. Low potassium levels (hypokalemia) are a severe concern, especially in the context of acute gastroenteritis where there can be significant losses through vomiting and diarrhea. Hypokalemia can lead to cardiac arrhythmias and needs urgent correction.

C. Weight loss of 3% of total body weight:
While weight loss is an important parameter, a 3% weight loss is usually not an immediate concern. In cases of acute gastroenteritis, rapid weight loss might indicate severe dehydration, but this choice is not as urgent as addressing a severe electrolyte imbalance like hypokalemia.

D. Urine specific gravity 1.035:
This specific gravity indicates concentrated urine, which could be due to dehydration. While this finding is important and indicates the need for rehydration, it is not as urgent as correcting a critically low potassium level.

A. Upper left quadrant B. Upper right quadrant C. Lower left quadrant D. Lower right quadrant

Correct Answer is C

Explanation

A. Upper left quadrant: Pain in the upper left quadrant of the abdomen can be associated with issues related to the spleen, stomach, or parts of the colon. It's not a typical location for pain related to diverticular disease.

B. Upper right quadrant: Pain in the upper right quadrant is often associated with issues related to the liver, gallbladder, or part of the colon. Again, not a typical location for diverticular disease-related pain.

C. Lower left quadrant: This is the correct answer. Diverticular disease often causes pain in the lower left quadrant of the abdomen, particularly if the inflammation or infection is in the sigmoid colon, which is a common site for diverticula.

D. Lower right quadrant: Pain in the lower right quadrant can be related to issues with the appendix or parts of the colon. It's not a typical location for diverticular disease-related pain.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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