A nurse is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?

Mark the length to be inserted on the tube with tape.

Place a water-based lubricant on the tip of the tube.

Compare the patency of the client's nares.

Instruct the client to hyperextend her neck.

Answer and Explanation

The Correct Answer is C

A. Mark the length to be inserted on the tube with tape.: This is done after the pathway is assessed but before insertion.

B. Place a water-based lubricant on the tip of the tube.: This is done immediately before insertion, not as the first step.

C. Compare the patency of the client's nares.: Following the Nursing Process (Assessment first), the nurse must determine which nostril is most patent to ensure the easiest passage for the tube.

D. Instruct the client to hyperextend her neck.: This is a position used during the initial insertion phase, but assessment of the nares must come first.

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Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

A. Elevate the client's hand above the level of the heart.: The hand should be kept dependent (below heart level) to increase blood flow to the fingertips.

B. Squeeze the client's finger until a blood drop forms.: Excessive squeezing (milking) can cause hemolysis or dilute the specimen with interstitial fluid.

C. Prick the side of the client's finger.: The sides of the finger have fewer nerve endings and better vascularity than the center of the fingertip.

D. Apply clean gloves.: Standard precautions must be followed when handling blood.

E. Cleanse the client's finger with an iodine swab.: Iodine can interfere with results (especially glucose). Alcohol is typically used and must be allowed to dry completely.

A. Goggles B. Mask C. Gloves D. Gown

Correct Answer is C

Explanation

A. Goggles: These are removed after the gown and gloves in most protocols.

B. Mask: The mask (or respirator) is always removed last to protect the nurse from airborne or droplet particles.

C. Gloves: Gloves are considered the most contaminated piece of PPE and should be removed first to prevent contaminating the rest of the body or environment during the removal of other items.

D. Gown: The gown is typically removed after the gloves.

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