A patient with a nasogastric (NG) tube in place is experiencing respiratory distress. What is the most appropriate initial nursing intervention?

Elevate the head of the bed to 90 degrees

Administer a bronchodilator as prescribed.

Check the placement of the NG tube to ensure it has not dislodged into the lungs.

Increase the flow rate of the patient’s oxygen therapy.

Answer and Explanation

The Correct Answer is C

A. Elevate the head of the bed to 90 degrees: While elevating the head of the bed may help ease breathing, it does not address the potential issue of NG tube misplacement.

B. Administer a bronchodilator as prescribed: This would only be appropriate if the patient’s respiratory distress were related to bronchospasm or asthma, not NG tube displacement.

C. Check the placement of the NG tube to ensure it has not dislodged into the lungs. When a patient with an NG tube experiences respiratory distress, the tube may have dislodged and entered the respiratory tract, which could obstruct breathing. Verifying the placement of the NG tube is critical to preventing aspiration or further complications.

D. Increase the flow rate of the patient’s oxygen therapy: This may provide temporary relief but does not resolve the underlying cause of the distress if the NG tube has entered the respiratory tract.

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Correct Answer is D

Explanation

A. "You will need to avoid high-fiber foods to prevent blockages": While caution with high-fiber foods may be needed initially, long-term, a balanced diet including fiber can help regulate bowel movements and prevent constipation. This statement could cause unnecessary concern.

B. "The output from your stoma will be mostly liquid": This statement is incorrect for a sigmoid colostomy, where the stool tends to be more formed since it is further along the digestive tract. Liquid output is more common with ileostomies or colostomies higher in the colon.

C. "You will need to change your colostomy bag every 24 hours":
Rationale: Colostomy bag changes depend on several factors, including the type of appliance and personal preferences. Bags are not changed on a strict 24-hour schedule but are emptied as needed and changed every few days or when required.

D. "Your stoma will be located on the left side of your abdomen." A sigmoid colostomy is typically located on the left lower quadrant of the abdomen, as this is the anatomical location of the sigmoid colon.

A. Encouraging the patient to drink ginger tea for nausea B. Applying ice packs to the abdomen C. Administering prescribed intravenous analgesics D. Advising the patient to eat small, frequent meals

Correct Answer is C

Explanation

A. Encouraging the patient to drink ginger tea for nausea: While ginger tea may help with nausea in some cases, it is not an appropriate intervention for acute cholecystitis, which requires more aggressive management.

B. Applying ice packs to the abdomen: Ice packs are not a standard treatment for acute cholecystitis and would not effectively alleviate the patient’s pain or inflammation.

C. Administering prescribed intravenous analgesics: The most appropriate intervention is to administer prescribed intravenous analgesics to relieve pain in patients with acute cholecystitis. Pain management is a priority to alleviate discomfort while awaiting further treatment, such as surgery or antibiotics.

D. Advising the patient to eat small, frequent meals: Dietary changes like eating small, frequent meals may be advised after the acute phase to prevent future attacks, but they are not appropriate for addressing acute symptoms.

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A patient with a nasogastric (NG) tube in place is experiencing respiratory distress. What is the most appropriate initial nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

Correct Answer is D

Explanation

A female patient presents with right upper quadrant pain, nausea and vomiting. She has been diagnosed with acute cholecystitis. What is the most appropriate nursing action to alleviate her symptoms?

Correct Answer is C

Explanation

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