A nurse is participating in the care plan for a patient with an intestinal obstruction who is undergoing continuous gastrointestinal decompression using a nasogastric tube.
What interventions should the nurse include in the care plan?
Daily measurement of abdominal girth.
Maintenance of the patient in Fowler’s position.
Moistening the patient’s lips with lemon glycerin swabs.
Use of sterile water to irrigate the nasogastric tube.
Correct Answer : A,B,D
Choice A rationale
Daily measurement of abdominal girth is crucial in patients with an intestinal obstruction undergoing continuous gastrointestinal decompression. This is because any changes in the abdominal girth can indicate an improvement or worsening of the obstruction. Regular monitoring allows for timely intervention and adjustment of the care plan.
Choice B rationale
Maintaining the patient in Fowler’s position can help promote the drainage of gastric contents via the nasogastric tube. This position, where the patient is seated in bed at an angle of 45-60 degrees, uses gravity to assist in the drainage process, thereby potentially alleviating discomfort and reducing the risk of aspiration.
Choice C rationale
Moistening the patient’s lips with lemon glycerin swabs is not recommended. While it’s important to keep the patient’s lips moist to prevent dryness and cracking due to the nasogastric tube, lemon glycerin swabs can potentially dry out the lips more and cause irritation.
Choice D rationale
Using sterile water to irrigate the nasogastric tube is a standard practice in managing patients with a nasogastric tube. This helps ensure the patency of the tube and prevent blockages, allowing for effective gastrointestinal decompression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Pushing the syringe plunger to empty the formula faster is not recommended. This can lead to complications such as aspiration, diarrhea, or abdominal cramping. The formula should be allowed to flow slowly by gravity.
Choice B rationale
Holding the syringe high enough for the formula to empty gradually by gravity is the correct method for intermittent feeding. This allows for a slow, controlled flow of the formula, which can help prevent complications.
Choice C rationale
Positioning the patient in a supine position during feeding is not recommended. The patient should be in an upright position, at least 30 degrees, to reduce the risk of aspiration.
Choice D rationale
Flushing the tubing before feeding only is not correct. The tubing should be flushed before and after feedings to maintain patency and prevent clogging.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Daily measurement of abdominal girth is crucial in patients with an intestinal obstruction undergoing continuous gastrointestinal decompression. This is because any changes in the abdominal girth can indicate an improvement or worsening of the obstruction. Regular monitoring allows for timely intervention and adjustment of the care plan.
Choice B rationale
Maintaining the patient in Fowler’s position can help promote the drainage of gastric contents via the nasogastric tube. This position, where the patient is seated in bed at an angle of 45-60 degrees, uses gravity to assist in the drainage process, thereby potentially alleviating discomfort and reducing the risk of aspiration.
Choice C rationale
Moistening the patient’s lips with lemon glycerin swabs is not recommended. While it’s important to keep the patient’s lips moist to prevent dryness and cracking due to the nasogastric tube, lemon glycerin swabs can potentially dry out the lips more and cause irritation.
Choice D rationale
Using sterile water to irrigate the nasogastric tube is a standard practice in managing patients with a nasogastric tube. This helps ensure the patency of the tube and prevent blockages, allowing for effective gastrointestinal decompression.
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