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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Answers:

Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.

A. The client holds the cane on the stronger side of their body. B. The client advances the cane forward 12.7 cm (5 in). C. The client moves their stronger leg forward first. D. The top of the cane is at the same height as the client's waist.

Correct Answer is A

Explanation

A. The client holds the cane on the stronger side of their body: Holding the cane on the stronger side improves balance and support while reducing strain on the weaker limb. It also helps coordinate movement and distribute weight more efficiently during ambulation.

B. The client advances the cane forward 12.7 cm (5 in): The cane should typically be advanced 15 to 25 cm (6 to 10 inches) forward for optimal support. Advancing it only 5 inches may provide insufficient balance assistance during walking.

C. The client moves their stronger leg forward first: The weaker leg should move forward after the cane to allow the stronger leg to support most of the weight. This pattern maximizes stability and safety during ambulation.

D. The top of the cane is at the same height as the client's waist: The cane should be level with the wrist crease when the client’s arms are relaxed at their sides, not at waist level. A cane that is too high or low can cause discomfort or improper posture.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client. Exhibits Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is dropdown followed by dropdown .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

Correct Answer is A

Explanation

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