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 A
Explanation
Choice A rationale
Placing clean linen that touched the floor in the soiled linen bag is a correct practice. This is because the floor is considered dirty, and any linen that comes into contact with it should be considered contaminated.
Choice B rationale
Shaking soiled linen to remove any toilet paper remnants is not a correct practice. Shaking soiled linen can disperse pathogens into the air, increasing the risk of disease transmission.
Choice C rationale
Placing the soiled linen on the floor before bagging it is not a correct practice. Soiled linen should be handled as little as possible and placed directly into a designated, leak-proof container.
Choice D rationale
Holding the soiled linen against her body while carrying it to the linen bag is not a correct practice. Soiled linen should be handled carefully to avoid contact with the body, as this can lead to contamination of the worker’s clothing and potentially spread infection.
Correct Answer is D
Explanation
Choice A rationale
Aspiration is not a common complication of TPN. TPN is administered intravenously, bypassing the gastrointestinal tract, which reduces the risk of aspiration. Choice B rationale
Polyuria, or excessive urination, is not typically a direct complication of TPN. However, the fluid balance of patients on TPN should be monitored, as both overhydration and dehydration can lead to urinary changes.
Choice C rationale
Stomatitis, or inflammation of the mouth and lips, is not a common complication of TPN. Since TPN bypasses the gastrointestinal tract, it does not typically cause oral complications.
Choice D rationale
Abdominal distention can occur as a complication of TPN. This is because TPN can cause an imbalance in the gut flora, leading to gas production and bloating. Additionally, if a patient on TPN has an underlying condition that affects gut motility, they may experience abdominal distention.
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