Nokea
When a client's nasogastric (NG) tube stops draining, which intervention should the nurse implement to maintain client safety?
- A. Instill 10 to 20 mL of fluid to dislodge any clots.
- B. Verify the tube placement according to agency procedure.
- C. Clamp the tube for 2 hours to allow the drainage to accumulate.
- D. Retract the tube by 2 inches to be above and possible obstruction.
Correct Answer: B
Rationale: If a client's nasogastric tube stops draining, the nurse verifies placement first to ensure that the tube remains in the stomach. After checking placement and verifying a prescription for tube irrigation, the nurse irrigates the tube with 30 to 60 mL of the fluid per agency procedure. Clamping the tube increases the risk of aspiration and is contraindicated; besides, this intervention cannot unclog a tube. Retracting the tube may displace the tube and place the client at risk for aspiration.
You may also like to solve these questions
The nurse inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, but as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which action if taken by the nurse at this point would indicate a need for further instruction regarding the insertion of an NG tube?
- A. Pulling the tube back slightly
- B. Instructing the client to breathe slowly
- C. Continuing to advance the tube to the desired distance
- D. Checking the back of the pharynx using a tongue blade and flashlight
Correct Answer: C
Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. The nurse should check the back of the pharynx using a tongue blade and flashlight to check for coiling and then pull the tube back slightly to prevent entrance into the larynx. Slow breathing helps the client relax to reduce the gag response.
The nurse is reviewing the laboratory results for a client who is receiving torsemide 5 mg orally daily. What value should indicate to the nurse that the client might be experiencing an adverse effect of the medication?
- A. A chloride level of 98 mEq/L (98 mmol/L)
- B. A sodium level of 135 mEq/L (135 mmol/L)
- C. A potassium level of 3.1 mEq/L (3.1 mmol/L)
- D. A blood urea nitrogen (BUN) level of 15 mg/dL (5.4 mmol/L)
Correct Answer: C
Rationale: Torsemide is a loop diuretic. The medication can produce acute, profound water loss; volume and electrolyte depletion; dehydration; decreased blood volume; and circulatory collapse. Option 3 is the only option that indicates electrolyte depletion because the normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal chloride level is 98 to 107 mEq/L (98 to 107 mmol/L). The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
Which action should the nurse take before performing a venipuncture to initiate continuous intravenous (IV) therapy?
- A. Apply a cool compress to the affected area.
- B. Inspect the IV solution and expiration date.
- C. Secure a padded arm board above the IV site.
- D. Apply a tourniquet below the venipuncture site.
Correct Answer: B
Rationale: IV solutions should be free of particles or precipitates to prevent trauma to veins or a thromboembolic event; in addition, the nurse avoids administering IV solutions whose expiration date has passed to prevent infection. Cool compresses cause vasoconstriction, making the vein less visible, smaller, and more difficult to puncture. Arm boards are applied after the IV is started and are used only if necessary. A tourniquet is applied above the chosen vein site to halt venous return and engorge the vein; this makes the vein easier to puncture.
A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
The nurse prepares the client for the removal of a nasogastric tube. During the tube removal, the nurse instructs the client to take which action?
- A. Inhale deeply.
- B. Exhale slowly.
- C. Hold in a deep breath.
- D. Pause between breaths.
Correct Answer: C
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal. The maneuver partially occludes the airway during tube removal; afterward, the client exhales as soon as the tube is out and thus avoids drawing the gastric contents into the trachea.