ADULT HEALTH 2 EXAM -REVISION GUIDE

ADULT HEALTH 2 EXAM -REVISION GUIDEADULT HEALTH 2 EXAM -REVISION GUIDE
After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side
lying position. The nurse understands that the purpose of this intervention is to accomplish
which?
Limit bleeding from the biopsy site
Rationale:
After a liver biopsy, the client is assisted with assuming a right side-lying position with a small
pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit
bleeding from the biopsy site. The liver produces bile that flows through the common bile duct;
client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not
the purpose of the right side-lying position.
The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should
place the client in which position for insertion?
High-Fowler's position
Rationale:
Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's
position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be
placed behind the head and shoulders to promote the client's ability to swallow during procedure.
Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.
The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct
placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in
the stomach?
Placement is verified on x-ray.
Rationale:
The end of the NG tube should be in the stomach. An x-ray is the most reliable method of
determining correct placement. The radiologist may recommend moving the tube backward or
forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be
from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump
inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach.
Auscultation of the air injection is not recommended as a reliable method to establish correct
placement.
ADULT HEALTH 2 EXAM -REVISION GUIDE
A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a
nasogastric (NG) tube from the client. Which interventions should be included in the
procedure? Select all that apply.
2.
3.
4.
5.
Explain the procedure to the client.
Ask the client to take a deep breath and hold.
Pull the tube out in one continuous steady motion.
Remove the device or tape securing the tube from the nose.
Rationale:
Before removing the tube, the client should be