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. 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.

A. Obtain the client's vital signs. B. Weigh the client. C. Change the client's dressing. D. Administer pain medication.

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.

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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 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?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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