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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fatty stools:
Obstruction of the common bile duct can result in impaired bile flow, leading to a decrease in bile salts reaching the intestine. This can result in the malabsorption of fats, causing fatty or greasy stools (steatorrhea).
B. Tenderness in the left upper abdomen:
Tenderness in the left upper abdomen might be more commonly associated with conditions like splenic issues or stomach problems rather than an obstruction of the common bile duct.
C. Straw-colored urine:
Straw-colored urine is typical of well-hydrated individuals and might not directly correlate with an obstruction of the common bile duct.
D. Ecchymosis of the extremities:
Ecchymosis (bruising) of the extremities is not typically associated with an obstruction of the common bile duct resulting from chronic cholecystitis.
Correct Answer is A
Explanation
Correct answer: A
A. Bear down:
Bear down: Asking the clientto bear down gently (as if to void) helps to expose urethral meatus.Bearing down simulates the act of urination and helps open the urethra.
B. Exhale slowly:
While exhaling slowly might help the client relax, it does not specifically assist with the insertion of the catheter as effectively as bearing down.
C. Contract the pelvic muscles:
Contracting the pelvic muscles (such as squeezing or tightening) might make catheter insertion more challenging by tensing the area where the catheter needs to pass through.
D. Take a sip of water:
Drinking water is not typically instructed during urinary catheter insertion, as it's unrelated to the process and might increase discomfort.
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