the client has orders for a nasogastric ng tube insertion during the procedure instructions that will assist in the insertion would be
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:

Correct answer: A

Rationale: Instructing the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion helps facilitate the NG tube insertion.

2. The nurse evaluates the client’s stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

Correct answer: B

Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.

3. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

4. The nurse is caring for a client following a Billroth II procedure. On review of the postoperative orders, which of the following if prescribed, should the nurse question and verify?

Correct answer: A

Rationale: In a Billroth II procedure the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation the nurse should clarify the order. Coughing and deep breathing exercises, leg exercises, and early ambulation are appropriate postoperative interventions.

5. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?

Correct answer: B

Rationale: After ileostomy closure surgery, it is recommended to eat six small meals a day to aid digestion and absorption.

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