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. Tremors:
Tremors or shaking is a common symptom of hypoglycemia. When blood glucose levels drop too low, the body reacts by releasing hormones like adrenaline, leading to symptoms such as tremors, shakiness, and palpitations.
B. Bradycardia:
Bradycardia, or a slow heart rate, is not typically associated with hypoglycemia. Instead, hypoglycemia tends to stimulate the release of adrenaline, which can increase heart rate.
C. Vomiting:
Vomiting is not a classic manifestation of hypoglycemia. Nausea may occur, but vomiting is more commonly associated with conditions such as hyperglycemia or diabetic ketoacidosis.
D. Fruity odor on the client’s breath:
A fruity odor on the breath is more commonly associated with diabetic ketoacidosis (DKA) in individuals with diabetes mellitus, particularly when there is an accumulation of ketones in the body. It is not a typical manifestation of hypoglycemia.
Correct Answer is A
Explanation
A. "Eat four small meals each day":
Smaller, more frequent meals reduce gastric distension and lower gastric pressure, which decreases reflux of stomach contents into the esophagus. Large meals increase intra-abdominal pressure and worsen GERD symptoms.
B. "Sleep on your left side":
Sleeping on the left side may reduce symptoms of GERD for some individuals. This position can keep the stomach below the esophagus, minimizing reflux. However, individual preferences and comfort should be considered.
C. "Wait to go to bed for 1 hour after eating":
This instruction helps reduce the risk of reflux while lying down. Waiting after eating allows gravity to aid in digestion and reduces the likelihood of stomach contents backing up into the esophagus during sleep.
D. "Drink milk to soothe your stomach":
While milk might provide temporary relief for some people by neutralizing stomach acid, it can stimulate acid production, potentially exacerbating GERD symptoms in the long run. Therefore, it's not a recommended solution for managing GERD.
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