A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?

Wear sterile gloves to insert the NG tube.

Ask the client to cough while inserting the NG tube.

Place the client into a left lateral position before inserting the NG tube.

Determine the length of the NG tube to be inserted prior to the procedure.

Answer and Explanation

The Correct Answer is D

Choice A reason: Sterile gloves are not required for inserting an NG tube; clean gloves are sufficient as the nasal
cavity is not a sterile environment.

Choice B reason: The client should not be asked to cough while inserting the NG tube as this could disrupt the placement process. Instead, the client may be asked to swallow to facilitate the passage of the tube.

Choice C reason: Placing the client into a left lateral position is not the standard position for NG tube insertion. The
client should be in an upright or semi-Fowler's position to aid in the insertion process.

Choice D reason: Determining the length of the NG tube to be inserted is a crucial step to ensure that the tube
reaches the stomach without coiling in the esophagus or extending into the small intestine.

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Correct Answer is C

Explanation

Choice A reason: Aspirating fluid from the IV cannula is not recommended as it does not address the issue of infiltration or extravasation.

Choice B reason: Placing the affected extremity below the level of the client's heart could worsen the swelling and is
not recommended.

Choice C reason: Slowing the IV infusion is a correct immediate action to minimize further infiltration and should be done while further assessment and interventions are planned.

Choice D reason: Placing a pressure dressing over the IV site is not recommended as it may exacerbate the infiltration
and increase discomfort.

A. Substernal retractions noted on the client's chest. B. Crackles auscultated over the client's lung fields C. Crepitus palpated on the client's chest. D. Dullness percussed over the client's lung fields

Correct Answer is D

Explanation

Choice A reason: Substernal retractions are not typically associated with pleural effusion; they are more indicative of conditions causing increased work of breathing.

Choice B reason: Crackles are usually heard in conditions like pneumonia or heart failure, but not typically in isolated pleural effusion unless it is associated with other lung conditions.

Choice C reason: Crepitus is generally associated with subcutaneous emphysema when air is present in the
subcutaneous tissue and is not a common finding in pleural effusion.

Choice D reason: Dullness on percussion over the lung fields is a classic finding in pleural effusion due to the presence of fluid in the pleural space.

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A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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