A nurse is planning to perform gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take.
Chill the lavage fluid before instilling it.
Position the client on his right side.
Withdraw the fluid manually until it is clear.
Insert a small-bore NG tube.
The Correct Answer is C
Choice A rationale
Chilling the lavage fluid causes vasoconstriction of the gastric blood vessels, which helps to slow or stop the bleeding. The cold temperature directly constricts the capillaries and arterioles in the stomach lining, reducing blood flow to the bleeding site. This action is a primary goal of gastric lavage in cases of upper gastrointestinal hemorrhage.
Choice B rationale
Positioning the client on their left side is the appropriate action. This position allows the lavage fluid to pool in the greater curvature of the stomach, where it can be most effective at washing over the bleeding site. Placing the client on their right side would cause the fluid to quickly pass into the duodenum, which is less effective for gastric lavage.
Choice C rationale
Gastric lavage is performed to remove blood and clots from the stomach. The procedure involves instilling a fluid, typically saline, and then withdrawing it. The nurse continues this process, manually withdrawing the fluid, until the return fluid is clear or only slightly pink, which indicates that the bleeding has been controlled or significantly reduced.
Choice D rationale
A large-bore NG tube (16-18 French or larger) is preferred for gastric lavage in cases of upper gastrointestinal bleeding. A large-bore tube is necessary to effectively remove blood clots and viscous fluid from the stomach. A small-bore tube would easily become occluded by clots, rendering the lavage procedure ineffective. *.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the rate of formula delivery would worsen hyperosmolar dehydration. A faster rate delivers more solute-rich formula to the gastrointestinal tract in a shorter time, pulling more free water from the body's vascular space into the gut lumen via osmosis. This fluid shift further depletes the body's free water, intensifying the dehydration and increasing serum osmolality.
Choice B rationale
Hyperosmolar dehydration occurs when the body's free water is drawn into the gastrointestinal tract due to a high solute concentration in the enteral formula. By adding free water to the formula, the nurse dilutes the solution, lowering its osmolarity. This action helps to balance the osmotic gradient, reducing the fluid shift and preventing further dehydration.
Choice C rationale
Switching to a lactose-free formula is indicated for clients with lactose intolerance, which causes symptoms like diarrhea and bloating, but it does not directly address hyperosmolar dehydration. Hyperosmolar dehydration is related to the overall solute load and concentration of the formula, not specifically the presence or absence of lactose.
Choice D rationale
Repositioning the NG tube is an action to ensure proper placement and prevent complications like aspiration, but it does not resolve hyperosmolar dehydration. This type of dehydration is a systemic problem related to fluid and electrolyte balance, not a local issue with the tube's position within the gastrointestinal tract. *.
Correct Answer is B
Explanation
Choice A rationale
Carbonated beverages contain gas that expands the stomach, increasing pressure on the lower esophageal sphincter (LES). This increased pressure can cause the LES to relax and allow gastric contents to reflux into the esophagus, exacerbating heartburn. Additionally, the acidic nature of many carbonated drinks can irritate the already inflamed esophageal lining.
Choice B rationale
Hot herbal tea can relax the esophageal muscles and soothe irritation. However, some herbal teas, like peppermint, can relax the lower esophageal sphincter, potentially worsening reflux. In contrast, chamomile or ginger tea may have a calming effect on the stomach and reduce inflammation, which can alleviate the symptoms of heartburn.
Choice C rationale
High-fat snacks, especially those consumed at bedtime, delay gastric emptying. The presence of food in the stomach for a prolonged period increases the risk of gastric reflux. Delayed emptying leads to a larger volume of stomach contents exerting pressure on the lower esophageal sphincter, making it more likely to open and allow acid to escape.
Choice D rationale
Lying down after meals increases the pressure on the lower esophageal sphincter and places the stomach contents in a position where gravity no longer helps keep them down. This postural change makes it easier for stomach acid to flow back into the esophagus, which is a primary cause of heartburn. Remaining upright for at least 30 minutes after eating is recommended. *.
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