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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Obtain the client's vital signs:
Vital signs are essential for assessing the client's overall condition and can provide crucial information about the client's stability. However, in this scenario, there's a higher priority nursing action that needs immediate attention.

B. Weigh the client:
Daily weight measurement is important, especially in postoperative patients, to monitor for fluid retention or loss. However, this is not the most urgent action in this situation.

C. Change the client's dressing:
Changing the dressing involves maintaining the surgical site's cleanliness and preventing infections. While this is important, it's not the highest priority in this situation.

D. Administer pain medication:
Correct Choice. Addressing the client's pain is a priority to ensure their comfort and well-being, especially postoperatively. Managing pain effectively is crucial for the client's recovery and can facilitate other necessary activities, such as changing the dressing or weighing the client.

A. "Do you take any recreational drugs?" B. "Did you have a blood transfusion recently? C. "Have you eaten any shellfish lately?" D. "Have you traveled to a third world country in the past two months?"

Correct Answer is D

Explanation

A. "Do you take any recreational drugs?"

This question is related to the risk of hepatitis transmission through the sharing of needles or other drug paraphernalia. Hepatitis B and C can be transmitted through contaminated needles used for injecting drugs.
B. "Did you have a blood transfusion recently?"

This question addresses the risk of hepatitis transmission through blood transfusions. While this used to be a significant risk, modern blood screening procedures have greatly reduced this risk. However, it's still a relevant question to understand the client's medical history.
C. "Have you eaten any shellfish lately?"

This question is related to the risk of hepatitis A transmission. Hepatitis A is often transmitted through contaminated food or water. Shellfish from contaminated waters can be a source of hepatitis A infection.
D. "Have you traveled to a third world country in the past two months?"

This question is crucial because hepatitis A is often more prevalent in developing countries and can be contracted through contaminated food, water, or poor sanitation. Travel history can help identify possible exposure sources.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is D

Explanation

A nurse is caring for a client who has hepatitis A. The client asks the nurse how he might have contracted the virus. Before responding, which of the following questions should the nurse first ask the client?

Correct Answer is D

Explanation

A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of gastroesophageal disease (GERD). Which of the following foods should the nurse include in the list of foods the client should avoid?

A nurse is collecting data from a client who has diverticular disease. The nurse should expect the client to report abdominal pain in which of the following locations?

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 ml. In the past 6 hr. The nurse should monitor the client for which of the following electrolyte Imbalances?

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?