NCLEX Daily Dose on the go: One Question at a Time

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?
1. Checking for normal serum electrolyte levels
2. Checking for normal pH of the gastric aspirate
3. Checking for proper nasogastric tube placement
4. Checking for the presence of bowel sounds in all four quadrants

Correct answer: 4

Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

Test-Taking Strategy:Eliminate options 2 and 3 first because they are comparable or alike. Assessing the pH of the gastric aspirate is one method of assessing tube placement. Also, note the strategic word, priority. Focus on the client's diagnosis to direct you to the correct option.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?
1. Bradycardia and hyperactivity
2. Decreased respiratory rate and depth
3. Headache, restlessness, and confusion
4. Bradypnea, dizziness, and paresthesias

Correct answer: 3

Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

Test-Taking Strategy:Focus on the subject, clinical manifestations associated with respiratory acidosis, and use knowledge of the signs and symptoms of respiratory acidosis to answer this question. Eliminate options 2 and 4 first because they are comparable or alike and address a decreased respiratory rate. Remember that headache, restlessness, and confusion occur in respiratory acidosis.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client?
1. "Take a deep breath when I tell you, and hold it while I remove the tube."
2. "Take a deep breath when I tell you, and bear down while I remove the tube."
3. "Take a deep breath when I tell you, and slowly exhale while I remove the tube."
4. "Take a deep breath when I tell you, and breathe normally while I remove the tube."

Correct answer: 1

Rationale: The client would take a deep breath, because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

Test-Taking Strategy:Focus on the subject, the procedure for removal of a nasogastric tube, and attempt to visualize the process of tube removal to direct you to the correct option. Remember, holding the breath facilitates the process of removal.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)?
1. Dark red drainage
2. Dark brown drainage
3. Green-tinged drainage
4. Light yellowish-brown drainage

Correct answer: 1

Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The PHCP needs to be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

Test-Taking Strategy:Focus on the subject, the need to notify the PHCP. Recall that bleeding is a concern in the postoperative client. This concept will direct you to the correct option.

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