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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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

A. Observing for changes in urinary patterns, such as a sudden decrease in urinary output or frequent, small amounts of voiding. This can indicate urinary retention, as frequent, small voids may suggest incomplete emptying of the bladder.

B. Assessing for reports of urinary hesitancy, dribbling of urine, straining, or a sensation of incomplete bladder emptying during urination. These symptoms are common in urinary retention, indicating that the client is having difficulty fully emptying the bladder.

C. Encouraging the client to drink large amounts of fluid in a short period to stimulate bladder emptying: This is incorrect, as overhydration can worsen urinary retention, especially in clients with an impaired ability to empty their bladder.

D. Applying pressure over the lower abdomen to force urine out of the bladder: This is incorrect and can cause harm, as it may increase the risk of bladder injury.

E. Evaluating for palpable bladder distention after voiding to assess incomplete bladder emptying.
A distended bladder after voiding suggests incomplete emptying and potential urinary retention.

A. Encourage the patient to use an alcohol-based mouthwash to clean the oral cavity. B. Advise the patient to avoid all oral intake until the ulcers heal completely. C. Suggest the patient to brush their teeth vigorously to remove any bacteria from the mouth D. Recommend the patient to consume soft, non-irritating foods and avoid acidic or spicy foods.

Correct Answer is D

Explanation

A. Encourage the patient to use an alcohol-based mouthwash to clean the oral cavity:
Alcohol-based mouthwashes can irritate the oral mucosa and worsen the pain of stomatitis. Instead, non-alcoholic, soothing mouth rinses are recommended.

B. Advise the patient to avoid all oral intake until the ulcers heal completely: Patients still need proper nutrition, and complete avoidance of food can lead to malnutrition. Soft, non-irritating foods are encouraged rather than full avoidance.

C. Suggest the patient brush their teeth vigorously to remove any bacteria from the mouth: Vigorous brushing can worsen oral ulcers and lead to further pain and bleeding. A gentle, soft-bristle toothbrush should be recommended.

D. Recommend the patient to consume soft, non-irritating foods and avoid acidic or spicy foods.
Consuming soft, bland, non-irritating foods and avoiding acidic or spicy foods helps reduce discomfort and prevent further irritation of oral ulcers, which is essential in managing stomatitis.

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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

When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A patient undergoing chemotherapy reports painful oral ulcers, difficulty eating, and a metallic taste in the mouth. The nurse suspects stomatitis. Which nursing intervention is most appropriate for this patient?

Correct Answer is D

Explanation

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