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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. To remove gastric acid that might cause dyspepsia:
This statement is not accurate. Measuring gastric residuals is not done to remove gastric acid but rather to ensure that the previous feeding has been digested and moved into the intestines before the next feeding is administered.
B. To identify delayed gastric emptying:This is the correct purpose. Measuring gastric residual helps assess whether the stomach is properly emptying its contents. High residual volumes can indicate delayed gastric emptying, which can increase the risk of aspiration and other complications during enteral feeding.
C. To determine the client's electrolyte balance:
Measuring gastric residuals is not used to assess the client's overall electrolyte balance. Electrolyte balance is typically assessed through blood tests and clinical evaluations, not by checking gastric residuals.
D. To confirm the placement of the NG tube:
Although verifying NG tube placement is critical before feeding, this is typically done by checking the tube’s external length, aspirating gastric contents, and confirming placement through pH testing or an X-ray, not by measuring gastric residual.
Correct Answer is ["A","B"]
Explanation
A. "I will consume less caffeine and spicy foods."
This statement is correct. Avoiding caffeine and spicy foods can help reduce stomach acid and prevent irritation, which is beneficial for individuals with hiatal hernia.
B. "I will sleep with the head of my bed elevated."
This statement is correct. Elevating the head of the bed can help prevent stomach acid from flowing back into the esophagus while sleeping, reducing symptoms like heartburn.
C. “I will lie down for one-half hour after meals."
This statement is incorrect. It's advisable for individuals with hiatal hernia to remain upright for at least two to three hours after meals to allow gravity to aid digestion and prevent acid reflux.
D. “I will drink less fluid."
This statement is incorrect. Adequate hydration is important for overall health. Drinking water between meals (not during meals) is generally recommended for individuals with hiatal hernia to prevent excess stomach distension during meals.
E. “To gain weight.”
This statement is not directly related to dietary recommendations for hiatal hernia. Weight gain or loss would depend on the individual's overall health goals and is not specific to managing hiatal hernia symptoms.
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