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Free NCLEX-RN Exam Braindumps (page: 183)

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A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:

  1. Lower lip to the shoulder to the upper sternum
  2. Tip of the nose to the lower lip to the umbilicus
  3. End of the tube to the first measurement line on the tube
  4. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

Answer(s): D

Explanation:

(A) This measurement is _50 cm (48­49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is _50 cm (47­48 cm). Fifty centimeters is considered the lengthnecessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.



A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:

  1. Lower lip to the shoulder to the upper sternum
  2. Tip of the nose to the lower lip to the umbilicus
  3. End of the tube to the first measurement line on the tube
  4. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

Answer(s): D

Explanation:

(A) This measurement is _50 cm (48­49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is _50 cm (47­48 cm). Fifty centimeters is considered the lengthnecessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.



A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:

  1. Monitoring the chest tubes
  2. Positioning the client on the right side
  3. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
  4. Monitoring the right lung for an increase in rales

Answer(s): D

Explanation:

(A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to re-expand on the operative side. (B) The pneumonectomy client should be positioned on the back or operated side because the sutured bronchial stump may open, allowing fluid to drain into the unoperated side and drown the client. (C) The client should not have a pillow under the shoulder and back because of the subscapular incision. (D) Rales are commonly heard over the base of the remaining lung, but an increase could indicate circulatory overload and therefore should be closely monitored.



A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:

  1. Monitoring the chest tubes
  2. Positioning the client on the right side
  3. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
  4. Monitoring the right lung for an increase in rales

Answer(s): D

Explanation:

(A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to re-expand on the operative side. (B) The pneumonectomy client should be positioned on the back or operated side because the sutured bronchial stump may open, allowing fluid to drain into the unoperated side and drown the client. (C) The client should not have a pillow under the shoulder and back because of the subscapular incision. (D) Rales are commonly heard over the base of the remaining lung, but an increase could indicate circulatory overload and therefore should be closely monitored.






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