The client experiencing abdominal distention and severe vomiting has just had a nasogastric (NG) tube inserted. When teaching this client, which rationale for the use of the NG tube should the nurse include?
Decompressing the stomach
Administering medications
Determining the pH of the gastric secretions
Supplying nutrients via tube feedings
The Correct Answer is A
A. One of the primary purposes of inserting an NG tube is to decompress the stomach by removing gastric contents. In the case of abdominal distention and severe vomiting, excess gas and fluid accumulation in the stomach can contribute to discomfort and further vomiting. The NG tube provides a way to suction out these contents, relieving pressure and reducing symptoms.
B. NG tubes can also be used to administer medications directly into the stomach. This route is particularly useful when a client is unable to take medications orally due to vomiting or other gastrointestinal issues. Medications can be crushed and dissolved in liquid form before being administered through the NG tube.
C. In some situations, such as when assessing for gastrointestinal bleeding or checking for tube placement, it may be necessary to determine the pH of gastric secretions. Gastric aspirate obtained through the NG tube can be tested for acidity, which can help confirm that the tube is correctly positioned in the stomach and provide information about the client's digestive function.
D. While NG tubes can be used to supply nutrients via tube feedings, this is not typically the primary rationale for their use in the acute situation described (abdominal distention and severe vomiting). However, in cases where a client is unable to tolerate oral intake due to their condition, tube feedings can be administered through the NG tube to provide essential nutrients and maintain nutritional status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. This intervention promotes emotional expression and allows the client to verbalize their fears, worries, and uncertainties related to the cancer diagnosis. Encouraging the client to express their feelings fosters a sense of emotional support, validation, and empathy, which are essential for coping with the emotional impact of the diagnosis.
C. Cancer diagnosis and treatment often involve multiple appointments, tests, and treatments, which can be overwhelming for the client. Assisting the client with time management and priorities can help alleviate stress and enhance coping by providing structure, organization, and support in managing the demands of the treatment plan and daily life responsibilities.
D. Involving the client in decision-making and allowing them input into the treatment plan empowers the client and promotes a sense of control and autonomy over their care. Collaborative decision-making enhances the client's engagement, adherence, and satisfaction with the treatment plan, which are essential for successful coping and treatment outcomes.
B. Telling the client what coping skills to use may not be the most effective approach, as it disregards the individuality of the client's coping mechanisms and preferences. Instead, the nurse should explore with the client what coping strategies they have used in the past and provide guidance and support in identifying and implementing effective coping strategies that align with the client's needs and preferences.
E. Providing extensive instructions about the treatment plan and prognosis is important for promoting understanding, informed decision-making, and adherence to the treatment plan. However, the timing and amount of information should be tailored to the client's readiness and preferences. Too much information too soon may overwhelm the client and hinder coping, while inadequate information may lead to uncertainty and anxiety. Therefore, the nurse should provide information in a clear, empathetic, and supportive manner, ensuring that the client's informational needs are met while respecting their emotional readiness.
Correct Answer is D
Explanation
D. Impaired immunity is a serious complication of prolonged stress that can have significant implications for overall health and susceptibility to illness. Chronic stress has been linked to dysregulation of the immune system, leading to decreased immune function and increased susceptibility to infections, autoimmune disorders, and other illnesses. Impaired immunity can compromise the body's ability to fight off pathogens and may contribute to the development or exacerbation of various health conditions.
A. Increased muscle tension is a common physiological response to stress but it is not typically considered a serious complication. Prolonged muscle tension can lead to discomfort, headaches, and musculoskeletal issues, but it is not usually life-threatening or associated with severe complications.
B. Altered sleep patterns, such as insomnia or disrupted sleep, can be significant consequences of prolonged stress. Chronic sleep disturbances can negatively impact physical health, cognitive function, and emotional well-being. While altered sleep patterns can have serious implications for overall health and quality of life, they are not typically considered life-threatening in the short term.
C. Increased peristalsis refers to heightened movement of the gastrointestinal tract, which can result in symptoms such as diarrhea or gastrointestinal discomfort. While gastrointestinal disturbances are common manifestations of stress, they are generally not considered the most serious complication of prolonged stress. However, severe or persistent gastrointestinal symptoms may warrant medical evaluation and management.
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