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
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.
Correct Answer is D
Explanation
A. Investigate the client's emotional concerns:
While addressing emotional concerns is important, assessing electrolyte imbalances and physiological stability takes precedence in managing an acute exacerbation of ulcerative colitis.
B. Check the client's perianal skin integrity:
Assessing perianal skin integrity is crucial, especially in inflammatory bowel disease, but it might not be the immediate priority compared to evaluating electrolyte imbalances.
C. Obtain a dietary history from the client:
Although dietary history is relevant for managing ulcerative colitis, the urgency lies in assessing and managing potential electrolyte imbalances due to the exacerbation of the condition.
D. Review the client's electrolyte values:
This is the correct action. During an acute exacerbation of ulcerative colitis, the client is at risk of electrolyte imbalances due to diarrhea, dehydration, and potential fluid and electrolyte losses. Promptly reviewing the electrolyte values helps identify any imbalances that might require immediate intervention.
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