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 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.
Correct Answer is A
Explanation
A. Avoid foods high in fat:
Dietary fat can trigger the gallbladder to release bile, and for individuals with chronic cholecystitis, high-fat meals can exacerbate symptoms such as biliary colic. Therefore, advising the client to avoid foods high in fat can help manage symptoms.
B. Include foods high in starch and proteins:
While protein-rich foods can be included in the diet, a high-fat content should be avoided. Starches can be a part of a balanced diet, but it's essential to focus on low-fat options.
C. Include foods high in fiber:
Including foods high in fiber is generally a good recommendation for digestive health. However, the emphasis here is on avoiding high-fat foods, and the recommendation for fiber should not overshadow the importance of minimizing dietary fat.
D. Avoid foods high in sodium:
Sodium restriction may be relevant for certain health conditions, but it is not the primary dietary consideration for managing chronic cholecystitis. The emphasis in this context is on reducing dietary fat.
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