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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Correct Answer is B

Explanation

A. Isopropyl alcohol: Alcohol is ineffective against C. diff spores.

B. Chlorine bleach: C. difficile is a spore-forming bacterium. Chlorine bleach (sodium hypochlorite) is one of the few disinfectants capable of killing these spores.

C. Chlorhexidine: This is an antiseptic for skin, not a surface disinfectant for spores.

D. Triclosan: This is an antibacterial agent often found in soaps that is ineffective against spores.

A. "My doctor will choose which medical procedures I will have." B. "My family can change the decisions in my living will." C. "I can revise my living will if I change my mind." D. "I need an attorney to write my living will."

Correct Answer is C

Explanation

A. "My doctor will choose which medical procedures I will have.": A living will is designed so the client chooses their preferences, specifically to ensure those wishes are honored if they cannot speak for themselves.

B. "My family can change the decisions in my living will.": Family members cannot override a legal living will; its purpose is to provide clear direction even if family members disagree.

C. "I can revise my living will if I change my mind.": A living will is a dynamic document; as long as the client remains competent, they can update or revoke it at any time.

D. "I need an attorney to write my living will.": An attorney is not legally required to create a living will, though the document must usually be witnessed or notarized according to state law.

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

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