Nokea
The nurse is caring for a client with a nasogastric tube (NGT) connected to suction. Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply.
- A. Draw up 30 mL of warm water into the syringe.
- B. Unclamp the suction tubing near the connection site to instill water.
- C. Place the tip of the syringe in the tube to gently instill warm water.
- D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
- E. After instilling the water, hold the end of the NG tube over an irrigation tray.
- F. Observe for return of NG drainage into an available container.
Correct Answer: A,C,F
Rationale: Using 30 mL of warm water (A), gently instilling it into the tube (C), and observing for drainage return (F) ensure proper NGT irrigation without complications. Unclamping suction (B) or using the air vent (D) is incorrect, and holding the tube over a tray (E) is unnecessary.
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A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting?
- A. Intermittent suction at 70 mmHg
- B. Intermittent suction at 100 mmHg
- C. Continuous suction at 100 mmHg
- D. Continuous suction at 70 mmHg
Correct Answer: A
Rationale: Intermittent suction at 70 mmHg (A) is appropriate for gastric decompression in bowel obstruction to prevent mucosal damage while effectively removing gastric contents.
The nurse is caring for a client with diverticulosis who reports difficulty getting enough dietary fiber. The nurse should anticipate the primary healthcare provider (PHCP) will prescribe
- A. Psyllium
- B. Oil-retention enema
- C. Codeine
- D. Bisacodyl
Correct Answer: A
Rationale: Psyllium, a bulk-forming laxative, increases fiber intake, promoting regular bowel movements in diverticulosis. Enemas, codeine (which slows motility), and bisacodyl (a stimulant laxative) are not appropriate for increasing dietary fiber.
The nurse is supervising a student nurse performing an abdominal assessment on a client with gastroenteritis. It would indicate effective technique if the student performs the assessment in which order?
- A. Auscultation, inspection, palpation, percussion
- B. Inspection, palpation, percussion, auscultation
- C. Palpation, percussion, inspection, auscultation
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation (D). Auscultation before palpation prevents altering bowel sounds.
The nurse is caring for a client with a hiatal hernia who is being discharged today. The nurse talks to them regarding methods to manage symptoms and promote overall well-being associated with their condition. Which of the following statements from the client indicate that teaching is successful?
- A. I need to wear loose-fitting clothes.
- B. After a meal, I must lie down to avoid dumping syndrome.
- C. I need to eat three large meals a day.
- D. I can go to my favorite Indian restaurant anytime of the week.
Correct Answer: A
Rationale: Wearing loose-fitting clothes (A) reduces pressure on the stomach, helping manage hiatal hernia symptoms. Lying down after meals (B) can worsen reflux, large meals (C) increase symptoms, and spicy foods (D) may exacerbate reflux.
The nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following client findings would indicate a therapeutic response?
- A. Decreased abdominal cramping
- B. Absence of nausea and vomiting
- C. Decreased urinary retention
- D. Less burning with urination
Correct Answer: A
Rationale: Dicyclomine, an anticholinergic, reduces intestinal spasms, so decreased abdominal cramping indicates a therapeutic response. It is not primarily for nausea, urinary retention, or dysuria.