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 C

Explanation

A. Monitor the client for manifestations of fluid overload: This action is not specifically related to C. difficile infection. Monitoring for fluid overload might be necessary in other situations, but it is not the appropriate action for this scenario.

B. Use alcohol hand sanitizer following client care: While alcohol-based hand sanitizers are effective against many pathogens, they are not effective against C. difficile spores. Washing hands with soap and water is necessary to remove the spores.

C. Disinfect equipment with bleach solution. This is the correct answer. Clostridium difficile (C. difficile) spores are resistant to many disinfectants, but they are killed by bleach. Therefore, equipment and surfaces should be cleaned with a bleach solution to prevent the spread of the infection.

D. Implement neutropenia isolation: Neutropenia isolation is a precautionary measure taken when a person has a low count of neutrophils, a type of white blood cell. This option is not directly related to C. difficile infection.

A. Perform leg exercises every 2 hr. B. irrigate the nasogastric tube every 4 to 8 hr. C. Maintain bed rest for 48 hr following surgery. D. Encourage hourly use of an incentive spirometer while awake. E. Document the color, consistency, and amount of nasogastric drainage.

Correct Answer is ["A","D","E"]

Explanation

A. Perform leg exercises every 2 hr: Performing leg exercises every 2 hours is essential for preventing blood clots and maintaining circulation in immobile patients. This is especially important after surgery to prevent complications like deep vein thrombosis.

B. Irrigate the nasogastric tube every 4 to 8 hr: Irrigating the nasogastric tube is not a standard nursing practice and should not be done without a physician's order. The nasogastric tube is typically used for decompression, drainage, or feeding. If the tube becomes clogged or there are concerns about drainage, the nurse should contact the healthcare provider for further instructions.

C. Maintain bed rest for 48 hr following surgery: While some bed rest might be necessary immediately after surgery, the goal is to encourage mobility as soon as possible to prevent complications such as atelectasis and deep vein thrombosis. Patients are usually encouraged to mobilize as soon as they are medically stable, often within hours after surgery.

D. Encourage hourly use of an incentive spirometer while awake: Using an incentive spirometer helps prevent atelectasis and promotes lung expansion after surgery. Encouraging the patient to use the incentive spirometer hourly while awake is a common nursing intervention to maintain respiratory function postoperatively.

E. Document the color, consistency, and amount of nasogastric drainage: Documenting the color, consistency, and amount of nasogastric drainage is crucial for monitoring the patient's condition. Changes in these factors could indicate bleeding, infection, or other complications, and timely documentation helps healthcare providers assess the patient's status and make appropriate interventions.

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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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