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Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Encouraging increased fluid intake helps maintain blood volume and reduces viscosity, promoting circulation and lowering the risk of venous stasis and clot formation postoperatively.
Choice B rationale: Keeping the affected knee flexed impairs venous return and increases stasis, elevating the risk of thrombosis. Proper positioning with extension promotes circulation and reduces clot risk.
Choice C rationale: Prolonged bed rest contributes to immobility-induced venous stasis, a major risk factor for DVT. Early ambulation and leg exercises are essential to prevent thromboembolic events.
Choice D rationale: Massaging the calf of a postoperative patient is contraindicated due to the risk of dislodging a thrombus, potentially leading to a life-threatening pulmonary embolism.
Correct Answer is C
Explanation
Choice A rationale:
This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.
It's important to validate the patient's experience and offer support, even if the pain level is not severe.
This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.
Choice B rationale:
This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.
Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.
Choice C rationale:
This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.
It is important to rule out any underlying medical conditions that may be causing the pain.
This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.
Choice D rationale:
This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.
This could lead to the patient feeling anxious or worried about their health.
It is important to investigate the cause of the pain before making any assumptions.
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