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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A pleural friction rub is associated with conditions that cause pleural inflammation, such as pleuritis or pneumonia, rather than Chronic Obstructive Pulmonary Disease (COPD). While patients with COPD may experience other abnormal lung sounds like wheezing or crackles, pleural friction rubs are not typically a feature of COPD.
Choice B reason: Peripheral edema is a common finding in clients with advanced COPD, particularly in those who develop right-sided heart failure (also known as cor pulmonale). The prolonged hypoxia and pulmonary hypertension that often accompany COPD can put additional strain on the right side of the heart, leading to fluid retention and swelling in the extremities. This is a typical finding in later stages of COPD.
Choice C reason: Spoon nails (koilonychia) are typically associated with iron deficiency anemia or other conditions affecting the circulatory system. Although COPD is a chronic respiratory condition that can impact oxygenation, spoon nails are not commonly associated with COPD. This condition is more commonly seen in anemia or other nutritional deficiencies.
Choice D reason:
Hyperresonance on percussion is a typical finding in COPD, especially in those with emphysema, where air trapping occurs. This is due to the destruction of lung tissue and the over-inflation of alveoli, which creates a more resonant sound when the chest is percussed. This finding indicates the presence of hyperinflated lungs, a hallmark of emphysema and a common component of COPD.
Correct Answer is A
Explanation
Choice A reason: An IV infusion of dextrose 10% in water can cause hyperglycemia, which is an elevated blood sugar
level.
Choice B reason: Hypovolemia, or decreased blood volume, is not a typical adverse effect of dextrose infusion.
Choice C reason: Hypercalcemia, or high calcium levels in the blood, is not associated with dextrose infusion.
Choice D reason: While dextrose infusion can affect electrolyte balance, hypokalemia, or low potassium levels, is not
the primary concern with dextrose infusion.
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