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Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement.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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Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Auscultate lung fields.
Choice A rationale:
Cupping hands and tapping on the patient’s chest is part of the chest percussion technique, which helps to loosen mucus. However, it is not the first step. Before performing any physical intervention, the nurse must assess the patient’s current respiratory status.
Choice B rationale:
Positioning the patient so that the lung area to be drained is above the trachea is part of postural drainage. This step is crucial but should be done after assessing the patient’s lung fields to determine the areas that need drainage.
Choice C rationale:
Providing mouth care is important for overall hygiene and to prevent infection, especially in patients with respiratory conditions. However, it is not directly related to the immediate assessment and intervention for chest physiotherapy.
Choice D rationale:
Auscultating lung fields is the first step because it allows the nurse to assess the patient’s respiratory status and identify areas with abnormal breath sounds, which will guide the subsequent interventions like chest percussion, vibration, and postural drainage. This assessment ensures that the interventions are targeted and effective.
Correct Answer is B
Explanation
Choice A rationale:
While explaining the importance and rationale of the new policy can be helpful, it may not address the underlying reasons for the nurse's resistance.
If the nurse does not understand or agree with the rationale, they may still be resistant to change.
Additionally, simply providing information may not create an open and trusting environment where the nurse feels comfortable expressing their concerns.
Choice B rationale:
Encouraging the nurse to verbalize their concerns allows the nurse manager to understand the specific reasons for the resistance.
This can help to identify any misconceptions or concerns that can be addressed directly.
It also gives the nurse an opportunity to feel heard and understood, which can help to build trust and rapport. When nurses feel that their concerns are being taken seriously, they are more likely to be open to change.
Choice C rationale:
Threatening disciplinary action is likely to create resentment and further resistance. It may also damage the relationship between the nurse manager and the nurse.
This approach should only be used as a last resort, after other attempts to address the resistance have failed.
Choice D rationale:
Ignoring the resistance is not an effective strategy.
It is likely to lead to continued noncompliance with the new policy,
It may also send the message that the nurse manager does not care about the nurse's concerns.
Peer pressure can sometimes be helpful in facilitating change, but it should not be relied upon as the sole strategy.
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