The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Measure the tube for insertion from the tip of the nose to the umbilicus.

Place the client in a supine position.

Withdraw the tube if the client gags during insertion.

Instruct the client to place his chin to his chest and swallow.

Answer and Explanation

The Correct Answer is D

Choice A: Measure the tube for insertion from the tip of the nose to the umbilicus. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should measure the tube for insertion from the tip of the nose to the earlobe and then to the xiphoid process, which is a more accurate way of estimating the length of the tube needed to reach the stomach.

Choice B: Place the client in a supine position. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should place the client in a high-Fowler’s position, which is a position with the head of the bed elevated to 90 degrees. This position can prevent aspiration, promote breathing, and allow gravity to assist with the insertion of the tube.

Choice C: Withdraw the tube if the client gags during insertion. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should not withdraw the tube if the client gags during insertion, as this can cause trauma to the nasal or pharyngeal mucosa and increase discomfort. The nurse should pause and allow the client to rest and breathe until gagging subsides, then resume insertion. The nurse should also provide reassurance and encouragement to the client throughout the procedure.

Choice D: Instruct the client to place his chin to his chest and swallow. This is an intervention that the nurse should take when inserting a nasogastric tube, which is a ﬂexible tube that is inserted through the nose and into the stomach. The nurse should instruct the client to place his chin to his chest and swallow as the tube passes through the pharynx and into the esophagus. This can facilitate the insertion of the tube and prevent it from entering the trachea or causing injury to the nasal or pharyngeal mucosa.

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Correct Answer is A

Explanation

Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.

Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side eﬀects.

Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.

Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or ﬂuid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.

Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by ﬂuid loss from vomiting and diarrhea. Weight loss can also reﬂect loss of muscle mass or fat tissue due to malnutrition or inﬂammation. Weight loss can aﬀect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.

A. Faty stools B. Ecchymosis of the extremities C. Straw-colored urine D. Tenderness in the left upper abdomen

Correct Answer is A

Explanation

Choice A: Faty stools. This is a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis, which is the presence of gallstones in the gallbladder or bile ducts. The common bile duct carries bile from the liver and gallbladder to the duodenum, where it helps digest fats. If the common bile duct is obstructed by a gallstone, bile cannot reach the duodenum and fats cannot be properly absorbed. This results in fatty stools, which are also known as steatorrhea. Fatty stools are pale, bulky, greasy, and foul-smelling.

Choice B: Ecchymosis of the extremities. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Ecchymosis of the extremities is a sign of bleeding under the skin, which can be caused by trauma, coagulation disorders, or medications. It is not related to bile duct obstruction or gallstones.

Choice C: Straw-colored urine. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Straw-coloured urine is a normal colour of urine, which indicates adequate hydration and kidney function. It is not aﬀected by bile duct obstruction or gallstones.

Choice D: Tenderness in the left upper abdomen. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Tenderness in the left upper abdomen is a sign of splenomegaly, which is an enlargement of the spleen due to infection, inﬂammation, or cancer. It is not related to bile duct obstruction or gallstones.

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The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

Correct Answer is A

Explanation

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