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 A
Explanation
A. Leave the needle in place for 10 seconds after the injection: Leaving the needle in place for approximately 10 seconds after administering a subcutaneous injection helps ensure full delivery of the medication and reduces the chance of medication leakage at the injection site.
B. Use a 5-inch needle for the injection: A 5-inch needle is excessively long for subcutaneous injections and would likely penetrate muscle tissue, increasing the risk of injury or incorrect medication administration. Subcutaneous injections typically require a needle length between ⅜ and ⅝ inch.
C. Inject the medication using the Z-track technique: The Z-track technique is used for intramuscular injections to minimize medication leakage and reduce irritation. It is not appropriate for subcutaneous injections, which are administered into the fatty layer beneath the skin, not deep muscle tissue.
D. Insert the syringe at a 15° angle during injection: A 15° angle is used for intradermal injections. Subcutaneous injections should be administered at a 45° to 90° angle depending on the client’s body mass to ensure the medication is delivered into the subcutaneous tissue, not the dermis or muscle.
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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