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 D
Explanation
Choice A reason: Warm water should be used to clean the skin, as hot water can cause further irritation.
Choice B reason: Friction should be avoided when drying the skin to prevent damage. The skin should be patted dry
gently.
Choice C reason: Soap can be too harsh and drying for the skin, especially if it is already compromised by incontinence. A mild, pH-balanced cleanser is recommended.
Choice D reason: A barrier cream is essential to protect the skin from moisture and irritants found in urine, which can lead to skin breakdown and incontinence-associated dermatitis.
Correct Answer is A
Explanation
Choice A reason: Tachycardia, or an abnormally rapid heart rate, is a common finding in circulatory overload due to
the increased volume of blood the heart must pump.
Choice B reason: Weight loss is not typically associated with circulatory overload. In fact, weight gain may occur due
to fluid retention.
Choice C reason: Diaphoresis, or excessive sweating, can be associated with circulatory overload as the body attempts to cool down due to the increased blood volume and workload on the heart.
Choice D reason: Hypotension, or low blood pressure, is not a usual finding in circulatory overload. Instead, hypertension may be more likely due to the increased volume of fluid in the blood vessels.
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