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.
Instruct the client to hyperextend her neck.
Place a water-based lubricant on the tip of the tube.
Compare the patency of the client's nares.
The Correct Answer is D
A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.
B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.
C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.
D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Registered dietitian: A dietitian can assess nutritional needs and recommend appropriate diets based on swallowing ability, but they do not directly evaluate or treat swallowing disorders. Their role becomes relevant after the dysphagia has been assessed and a safe diet established.
B. Respiratory therapist: Respiratory therapists focus on managing breathing and airway clearance, which can be important if aspiration pneumonia occurs. However, they do not assess or treat the swallowing difficulties themselves.
C. Speech-language pathologist: Speech-language pathologists evaluate and treat swallowing disorders as well as communication impairments following stroke. They perform swallowing assessments and develop individualized therapy plans to improve swallowing safety and function.
D. Occupational therapist: Occupational therapists assist clients with regaining independence in activities of daily living but do not specialize in swallowing assessments or treatments. Their focus is more on motor skills, cognition, and adaptive strategies.
Correct Answer is A
Explanation
A. Removing blankets from the client helps reduce external heat sources and allows body heat to dissipate, which can aid in lowering the elevated temperature. This action supports the body’s natural cooling mechanisms and provides comfort during a febrile state.
B. Placing cold packs on the axillae can help lower body temperature by cooling major blood vessels near the skin’s surface. However, this method may cause discomfort or shivering, which can paradoxically increase metabolic heat production and is less preferred than removing excess coverings.
C. Using a fan to blow air across the client promotes evaporative cooling, but if the client is shivering or chills are present, this can increase discomfort and cause the body to generate more heat. Fans are best used when the client is comfortable and not experiencing chills.
D. Giving an alcohol sponge bath is generally discouraged because alcohol is rapidly absorbed through the skin and can cause toxicity. Additionally, it can cause vasodilation, which might lead to increased heat loss and potential hypothermia if not carefully monitored.
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