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 D
Explanation
D. This is the most appropriate technique for evaluating the success of teaching a client a psychomotor skill. A return demonstration involves the client independently performing the skill they have been taught while the nurse observes. This allows the nurse to assess the client's ability to execute the skill correctly, including aspects such as technique, coordination, and safety precautions. Additionally, the nurse can provide immediate feedback and correction if necessary, enhancing the client's learning experience.
A. While answering oral questions can assess the client's understanding of theoretical or conceptual knowledge, it may not effectively evaluate their ability to perform a psychomotor skill. Psychomotor skills involve physical actions and coordination, which cannot be adequately assessed through verbal responses alone.
B. Participating in a discussion group can facilitate sharing of experiences and perspectives among clients, but it may not be the most effective method for evaluating the client's ability to perform a psychomotor skill. Discussion groups are more suitable for exploring attitudes, beliefs, and understanding of concepts rather than assessing physical skills.
C. Written tests typically assess cognitive understanding and retention of information rather than the ability to perform psychomotor skills. While written tests can evaluate knowledge about the steps involved in a skill, they do not directly assess the client's ability to execute the skill itself.
Correct Answer is ["A","C","E"]
Explanation
A. This action could pose a significant liability risk as it violates the standard of care, which includes providing thorough and accurate handoff communication to ensure continuity of care. Failing to provide a report before transferring a client to ICU could lead to miscommunication, errors in treatment, and compromised patient safety.
C. Documenting vital signs taken by another nurse is generally acceptable as long as the nurse ensures the accuracy of the information and documents according to institutional policies and standards. However, if the nurse knowingly documents false or inaccurate vital signs, it could pose a liability risk.
E. Using equipment with a frayed cord poses a significant liability risk as it could lead to electrical hazards, equipment malfunction, or patient injury. Nurses have a duty to ensure the safety and integrity of equipment used in patient care and should promptly report any defects or safety concerns to prevent harm to patients.
B. Completing the admission assessment is a standard nursing responsibility and is not inherently a liability risk. However, liability could arise if the assessment is incomplete, inaccurate, or not documented appropriately, leading to errors in care or failure to identify and address the client's needs
D. Calling the physician to request an order for pain medication is a routine nursing responsibility and is not inherently a liability risk. However, liability could arise if the nurse fails to communicate important information about the client's condition or medication history, resulting in inappropriate or unsafe prescribing practices.
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