A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take?

Attach the client's NG tube to low intermittent suction.

Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time.

Instill chilled lavage solution into the client's NG tube.

Use 0.9% sodium chloride for irrigation of the NG tube.

Answer and Explanation

The Correct Answer is D

A. Attach the client's NG tube to low intermittent suction: Suction may be used after lavage for decompression, but during lavage, the focus is on instilling and withdrawing solution manually to clear the stomach of blood or contents.
B. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time: This volume is excessive and could increase the risk of aspiration or discomfort. Typically, 100–200 mL is used per instillation.
C. Instill chilled lavage solution into the client's NG tube: Chilled solutions are not recommended as they may induce hypothermia and have not been shown to effectively control bleeding. Room-temperature solution is preferred.
D. Use 0.9% sodium chloride for irrigation of the NG tube: Isotonic saline is the recommended solution for gastric lavage, as it helps prevent electrolyte imbalance and irritation.

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Correct Answer is A

Explanation

A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.

B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.

C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.

D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.

A. Restrict visits from young children to 2 hr per day. B. Avoid including raw fruits in the client's diet. C. Measure the client's temperature every 8 hr. D. Use disposable gloves from a box outside the client's room.

Correct Answer is B

Explanation

A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.

B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.

C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.

D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.

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