A nurse is attending to a patient with a bowel obstruction who has been prescribed a nasogastric tube. What steps should the nurse take during the insertion of the nasogastric tube?
Remove the tube if the patient gags during insertion.
Advise the patient to tuck his chin to his chest and swallow.
Position the patient in a supine position.
Measure the tube for insertion from the nose tip to the navel.
The Correct Answer is B
Choice A rationale:
Removing the tube immediately upon patient gagging is not the most appropriate first step. Gagging is a common reflex during nasogastric tube insertion and can often be managed without removing the tube.
Premature removal could lead to unnecessary discomfort for the patient and potential delays in treatment.
The nurse should attempt to reposition the tube or have the patient sip water to facilitate passage before considering removal.
Choice B rationale:
Tucking the chin to the chest and swallowing are essential maneuvers that help guide the tube into the esophagus and reduce the risk of misplacement into the trachea.
These actions close off the airway and open the esophagus, creating a smoother path for the tube.
The nurse should instruct the patient to perform these actions during insertion to promote successful placement.
Choice C rationale:
While a supine position is often used for nasogastric tube insertion, it is not the most crucial factor for success.
Studies have shown that a high-Fowler's position (sitting upright with head elevated) may be equally effective and potentially more comfortable for patients.
The nurse should consider patient comfort and potential contraindications (such as respiratory distress) when choosing the most appropriate position.
Choice D rationale:
Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement. The correct measurement is from the nose tip to the earlobe to the xiphoid process (NEX).
This landmark-based method provides a more reliable estimation of the distance to the stomach.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Metabolic alkalosis is characterized by a high pH (above 7.45), high bicarbonate (HCO3-) levels, and normal or low PaCO2. The patient's ABGs show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg), which are not consistent with metabolic alkalosis.
Choice C rationale:
Respiratory alkalosis is characterized by a high pH (above 7.45), low PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low PaCO2, but the pH is low (acidic) and the bicarbonate is low, which are not consistent with respiratory alkalosis.
Choice D rationale:
Respiratory acidosis is characterized by a low pH (below 7.35), high PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low pH, but the PaCO2 is also low, which is not consistent with respiratory acidosis.
Rationale for the correct answer, B:
Metabolic acidosis is characterized by a low pH (below 7.35), low bicarbonate levels, and normal or low PaCO2. The patient's ABGs are consistent with metabolic acidosis because they show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg).
Acute kidney injury is a common cause of metabolic acidosis. The kidneys play a vital role in regulating acid-base balance by excreting acids and reabsorbing bicarbonate. When the kidneys are damaged, they are unable to excrete acids effectively, leading to an accumulation of acids in the blood and a decrease in bicarbonate levels.
Additional Information:
It's important to note that the patient's low PaCO2 is likely a compensatory mechanism for the metabolic acidosis. In response to acidosis, the respiratory system tries to increase ventilation to blow off more carbon dioxide, which helps to raise the pH. However, this compensatory mechanism is often not enough to fully correct the acidosis.
Correct Answer is A
Explanation
Choice A rationale:
It is crucial for the nurse to prioritize patient safety and adhere to professional guidelines when encountering a potential diversion of controlled substances. Informing the charge nurse is the most appropriate initial action for several reasons:
Chain of Command: The charge nurse holds a supervisory position and is responsible for addressing issues within the unit, including concerns about medication diversion. Reporting suspicions to the charge nurse ensures adherence to the established chain of command and facilitates a prompt, organized response.
Confidentiality and Objectivity: The charge nurse is trained to handle sensitive situations discreetly and objectively. They can initiate a thorough investigation while maintaining confidentiality and protecting the rights of all involved parties.
Access to Resources: The charge nurse has access to resources and authority to take immediate action, such as securing medications, initiating patient assessments, and notifying appropriate personnel within the healthcare facility.
Collaboration and Support: The charge nurse can provide guidance and support to the reporting nurse, ensuring their concerns are addressed appropriately and that they feel safe in coming forward with their suspicions.
Rationale for other choices:
B. Reporting the incident directly to the hospital’s security department might be premature without first informing the charge nurse. The charge nurse can assess the situation, gather more information, and determine the most appropriate course of action, which may or may not involve security at this initial stage.
C. Requesting assistive personnel (AP) to monitor the other nurse’s actions is inappropriate. It places a burden on APs who are not trained or authorized to investigate such matters. It could also compromise the integrity of the investigation and potentially jeopardize patient safety.
D. Confronting the other nurse directly is not recommended. It could escalate the situation, create a hostile work environment, and potentially compromise the investigation. It is essential to follow established protocols and involve appropriate personnel to ensure a fair and thorough investigation.
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