A nurse is caring for a client who has a nasogastric (NG) tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?

Reposition the NG tube.

Inject 20 mL of air and aspirate in the NG tube.

Instill an irrigation solution slowly.

Check the functioning of the suction equipment.

Answer and Explanation

The Correct Answer is D

Choice A reason: Repositioning the NG tube is a later step; checking suction function is first, as equipment failure is a common cause of no drainage. Assuming repositioning is initial risks delaying simple fixes, potentially prolonging discomfort, critical to avoid in ensuring effective gastric decompression.

Choice B reason: Injecting air and aspirating is a troubleshooting step but follows checking suction equipment, which may resolve no drainage. Assuming air injection is first risks unnecessary intervention, potentially causing discomfort, critical to prevent in ensuring efficient NG tube management for gastric decompression.

Choice C reason: Instilling irrigation solution is a later step after confirming suction function, as equipment issues are more common. Assuming irrigation is first risks clogging or discomfort, critical to avoid in ensuring proper NG tube function and effective gastric decompression in clients with non-draining tubes.

Choice D reason: Checking suction equipment function is the first step for a non-draining NG tube, as equipment failure is a common issue, easily corrected. This ensures effective decompression, critical for preventing gastric distention, supporting client comfort, and guiding further troubleshooting in managing NG tube care.

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Correct Answer is C

Explanation

Choice A reason: Protamine sulfate reverses heparin, not midazolam, a benzodiazepine requiring flumazenil for reversal. Assuming protamine is needed risks ineffective response to oversedation, critical to avoid in ensuring rapid reversal and safety in clients post-moderate sedation with midazolam in surgical settings.

Choice B reason: Acetylcysteine treats acetaminophen overdose, not midazolam, reversed by flumazenil. Assuming acetylcysteine is appropriate risks delayed reversal of sedation, potentially causing respiratory depression, critical to prevent in ensuring safe recovery for clients post-moderate sedation with midazolam in postoperative care.

Choice C reason: Flumazenil reverses midazolam’s benzodiazepine effects, critical for managing oversedation or respiratory depression post-moderate sedation. Having it on hand ensures rapid response, essential for client safety, preventing complications, and supporting recovery in surgical settings using midazolam for procedural sedation.

Choice D reason: Naloxone reverses opioids, not midazolam, a benzodiazepine requiring flumazenil. Assuming naloxone is needed risks ineffective treatment of sedation, potentially prolonging respiratory risks, critical to avoid in ensuring proper reversal and safety in clients post-moderate sedation with midazolam.

A. Supervise return demonstration of diaphragm use. B. Determine the client’s knowledge about diaphragm use. C. Teach the client how to insert the diaphragm. D. Document the client’s level of understanding about potential adverse effects.

Correct Answer is B

Explanation

Choice A reason: Supervising return demonstration follows teaching, not initial assessment; determining knowledge is first. Assuming demonstration is the first step risks ineffective education, potentially leading to misuse, critical to avoid in ensuring proper diaphragm use and contraception efficacy for female clients.

Choice B reason: Determining the client’s knowledge about diaphragm use is the first step, guiding tailored education and ensuring effective use. This assessment is critical for addressing gaps, promoting adherence, preventing contraceptive failure, and supporting informed decision-making in female clients requesting diaphragms for contraception.

Choice C reason: Teaching insertion follows assessing knowledge, which identifies educational needs. Assuming teaching is first risks overlooking client understanding, potentially leading to incorrect use, critical to prevent in ensuring effective diaphragm contraception and client safety in reproductive health care.

Choice D reason: Documenting understanding is a later step after assessing and teaching; determining knowledge is priority. Assuming documentation is first risks premature recording, potentially missing educational needs, critical to avoid in ensuring comprehensive diaphragm education and effective contraception for female clients.

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A nurse is caring for a client who has a nasogastric (NG) tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a procedure that required moderate sedation using midazolam. Which of the following should the nurse have on hand?

Correct Answer is C

Explanation

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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