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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Free Nursing Study Resources

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.

A. Slight bleeding of the stoma site B. Purplish colored stoma C. No stool noted in the collection bag D. Edematous stoma

Correct Answer is B

Explanation

A. Slight bleeding of the stoma site: This is typically normal in the immediate postoperative period. It's caused by surgical trauma and should improve with time. However, if it becomes excessive, it should be reported.

B. Purplish colored stoma: A purplish or bluish color of the stoma can be an indication of inadequate blood supply (ischemia). This is a concerning finding and should be reported promptly to the provider.

C. No stool noted in the collection bag: It's normal not to have stool in the collection bag immediately after surgery since the digestive system needs time to resume normal function. This is usually not a concern within the first 12 hours postoperatively. However, if it continues beyond this time frame, it should be reported.

D. Edematous stoma: Some edema or swelling around the stoma site can be normal initially after surgery. However, if the stoma becomes significantly edematous or starts to compromise blood flow, this should be reported to the provider.

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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 preparing to administer hydroxyzine HCL 50 mg PO. Available is hydroxyzine oral suspension 25 mg/5 mL. How many ml. should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

A nurse is collecting data from a client who is 12 hr postoperative following a colectomy with colostomy placement. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

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