A nurse is performing gastric lavage on a client using a large-bore NG tube. Which of the following actions should the nurse take?
Position the client on the right side.
Instill 1000 mL of sterile saline.
Withdraw fluid until it is clear.
Connect the NG tube to high continuous suction.
The Correct Answer is C
A. Positioning the client on the right side is not a standard recommendation for gastric lavage. The standard position is typically on the left side to facilitate the drainage of gastric contents.
B. Instilling 1000 mL of sterile saline is not a recommended action for gastric lavage. Gastric lavage involves the removal of stomach contents rather than instilling fluids.
C. Withdrawing fluid until it is clear is the correct action. Gastric lavage is a medical procedure used to empty the stomach contents. The process involves introducing small amounts of fluid (such as saline) into the stomach and then aspirating it back, along with gastric contents, until the aspirate is clear.
D. Connecting the NG tube to high continuous suction is not a standard approach for gastric lavage. Gastric lavage involves intermittent instillation and withdrawal of small amounts of fluid to clear the stomach.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Is used to replace fluid loss.
Isotonic solutions, such as normal saline (0.9% NaCl) and lactated Ringer's solution, are used to replace fluid loss in situations such as dehydration, surgery, trauma, or other conditions where there is a need for fluid resuscitation.
B. Usually do not provide calories.
Isotonic solutions typically do not contain calories. They are designed primarily for fluid replacement and do not contribute to the nutritional needs of the patient.
C. Does not expand intravascular volume.
This statement is incorrect. Isotonic solutions are used to expand intravascular volume. When infused into the bloodstream, isotonic solutions help restore and maintain adequate blood volume. They do not cause significant shifts of fluids between compartments.
D. Mostly do not provide free water.
Isotonic solutions generally do not provide free water. They have the same osmolality as body fluids, meaning that they do not cause a net movement of water into or out of cells, and they maintain the osmotic balance.
E. Has the same osmolality as body fluids.
Isotonic solutions have the same osmolality as body fluids, which means they do not cause a net movement of water into or out of cells. This characteristic makes them suitable for situations where there is a need to expand intravascular volume without causing significant shifts in fluid compartments.
Correct Answer is B
Explanation
A. Blood glucose level below 40 mg/dL is not typical in diabetic ketoacidosis. DKA is characterized by hyperglycemia, and blood glucose levels are usually significantly elevated.
B. Acetone odor to breath is a classic sign of diabetic ketoacidosis. The presence of ketones, including acetone, can result in a fruity or sweet odor to the breath. This is often referred to as "ketone breath."
C. Malignant hypertension is not a typical manifestation of diabetic ketoacidosis. DKA is more commonly associated with dehydration, electrolyte imbalances, and metabolic acidosis.
D. Cheyne-Stokes breathing is not a characteristic respiratory pattern seen in diabetic ketoacidosis. Respiratory changes in DKA are more likely to involve rapid and deep breathing (Kussmaul respirations) as the body attempts to compensate for metabolic acidosis.
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