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
Explanation
A. Obstruction of the bile duct:
Biliary cirrhosis can result from chronic obstruction of the bile ducts, leading to damage to the liver tissue. This obstruction can be due to various causes, such as gallstones or strictures.
B. Hepatotoxic medications:
While certain medications can contribute to liver damage, biliary cirrhosis specifically refers to conditions affecting the bile ducts. Hepatotoxic medications may contribute to cirrhosis but not necessarily biliary cirrhosis.
C. Hepatitis C:
Hepatitis C is a viral infection that primarily affects the liver. While chronic hepatitis C infection can lead to cirrhosis, it is not synonymous with biliary cirrhosis.
D. Excessive alcohol consumption:
Excessive alcohol consumption is a common cause of cirrhosis, but biliary cirrhosis specifically refers to cirrhosis resulting from chronic obstruction of the bile ducts.
Correct Answer is B
Explanation
A. Testing the client's emesis for blood is an important assessment, but assessing orthostatic blood pressure is a priority. Orthostatic blood pressure measurement helps identify if the client is experiencing significant blood loss, as changes in blood pressure upon standing may indicate hypovolemia.
B. Assessing orthostatic blood pressure is the priority action. Orthostatic hypotension can be a sign of decreased circulating blood volume, which is a concern in clients with gastrointestinal bleeding.
C. Explaining the procedure for an upper gastrointestinal series is not the first priority. While diagnostic tests may be needed, addressing the immediate concern of potential hypovolemia takes precedence.
D. Administering pain medication is not the first action. The priority is to assess and address the potential complications of gastrointestinal bleeding, such as hypovolemia.
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