3-2-1 Code It
6th Edition
ISBN: 9781337660549
Author: GREEN
Publisher: Cengage
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Paralytic ileus is a possible postoperative complication. To check for it, which of the following should be done?
a.
Administer antibiotics
b.
Observe and monitor patient heart rate
c.
Monitor renal function
d.
Auscultate for bowel sounds every 4 hours
A client returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Select all that apply.
a.
When irrigating the nasogastric tube, use sterile water
b.
Document the consistency and amount of drainage
c.
Wear sterile gloves when irrigating the nasogastric tube
d.
Wear nonsterile gloves when emptying the drainage container
e.
Apply water-soluble lubricant if the client’s lips are dry
A nurse is caring for a patient who has a nasogastric tube inplace for gastric decompression. Which nursing actions areappropriate when irrigating a nasogastric tube connected tosuction? Select all that apply.a. Draw up 30 mL of saline solution into the syringe.b. Unclamp the suction tubing near the connection site toinstill solution.
c. Place the tip of the syringe in the tube to gently insertsaline solution.d. Place syringe in the blue air vent of a Salem sump ordouble-lumen tube.e. After instilling irrigant, hold the end of the NG tube overan irrigation tray.f. Observe for return flow of NG drainage into an availablecontainer.
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- Which nursing action is essential in the prevention of pressure ulcers? A) Keeping the patient in one position B) Frequent skin assessments and repositioning C) Applying high-pressure mattresses D) Limiting fluid and nutritional intakearrow_forwardIn pediatric dehydration, which sign is commonly used to assess the severity of dehydration? A) Increased salivation B) Sunken fontanelles C) Bulging eyes D) Cold, clammy skinarrow_forwardWhile administering oxygen to an infant with Tetralogy of Fallot (TOF) who is having a hypoxic episode, the practical nurse (PN) should implement which intervention? A Hold the infant in a knee-chest position. B Give a prescribed diuretic medication. C Position the infant in Trendelenburg. D Administer liquid acetaminophen drops (gtt).arrow_forward
- A nurse is administering a tube feeding for a patient who ispost bowel surgery. When attempting to aspirate the contents,the nurse notes that the tube is clogged. What would be thenurse’s next action following this assessment?a. Use warm water and gentle pressure to remove the clog.b. Use a stylet to unclog the tubes.c. Administer cola to remove the clog.d. Replace the tube with a new one.arrow_forwardAn infant diagnosed with pyloric stenosis recently developed projectile vomiting. Which finding indicates to the practical nurse that the infant is becoming dehydrated? A Bulging fontanel. B Weak cry without any tears. C Visible peristaltic wave. D Palpable mass in the right upper quadrant.arrow_forwardThe nurse is administering a medication to a patient via anasogastric tube. Which are accurate guidelines related to thisprocedure? Select all that apply.a. Crush the enteric-coated pill for mixing in a liquid.b. Flush open the tube with 60 mL of very warm water.c. Check for proper placement of the nasogastric tube.d. Give each medication separately and flush with waterbetween each drug.e. Lower the head of the bed to prevent reflux.f. Adjust the amount of water used if patient’s fluid intake isrestricted.arrow_forward
- Need b , c and darrow_forwardAssess bowel elimination using appropriateinterview questions and physical assessmentskills.arrow_forwardWhat is an essential nursing intervention for a patient with a pressure ulcer? A) Limit mobility to reduce friction B) Apply a dry dressing to absorb moisture C) Keep the skin clean and dry, and reposition the patient frequently D) Increase the time between repositioning to rest the skinarrow_forward
- Marcus will be placed on lansoprazole (Prevacid) 30 mg orally daily to decrease the production of hydrochloric acid.a. How does lansoprazole decrease gastric acid production?b. What is the difference between the actions of lansoprazole and ranitidine?arrow_forwardThe rectal temperature, a core temperature, is considered to beone of the most accurate routes. In which cases would taking arectal temperature be contraindicated? Select all that apply.a. A newborn who has hypothermiab. A child who has pneumoniac. An older patient who is post myocardial infarction(heart attack)d. A teenager who has leukemiae. A patient receiving erythropoietin to replace red blood cellsf. An adult patient who is newly diagnosed with pancreatitisarrow_forwardA patient who is moved to a hospital bed following throat sur-gery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of thetube, which nursing action would the nurse initiate to ensurecorrect placement of the tube?a. Auscultate the bowel sounds.b. Measure the gastric aspirate pH.c. Measure the amount of residual in the tube.d. Order radiographic examination of the tube.arrow_forward
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