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 B

Explanation

A. Take a calcium supplement: Calcium supplements can contribute to constipation by decreasing bowel motility and hardening stools. Recommending calcium without addressing constipation can worsen symptoms.

B. Consume probiotic sources: Probiotics help balance gut flora and improve bowel motility, which can alleviate constipation. Including probiotic-rich foods like yogurt or supplements supports healthier digestion.

C. Use a laxative every day: Daily use of laxatives can lead to dependency and decreased bowel function over time. Laxatives should be used cautiously and not as a first-line or chronic treatment.

D. Bake with white flour: White flour is low in fiber and can contribute to constipation. Whole-grain alternatives are recommended to increase fiber intake and improve bowel regularity.

A. An assistive personnel is late for the upcoming shift. B. A client refuses to eat at mealtime. C. A family member is napping in the client's room. D. A client's bed alarm is malfunctioning.

Correct Answer is D

Explanation

A. An assistive personnel is late for the upcoming shift: Tardiness is an issue of staff performance or scheduling rather than client safety, and it should be addressed through administrative or managerial processes. It does not require an incident report unless it directly results in harm or neglect to a client.

B. A client refuses to eat at mealtime: Client refusal to eat is a common occurrence and is managed through nutritional assessments and care planning. While it should be documented in the medical record, it does not constitute an unusual or adverse event that requires an incident report.

C. A family member is napping in the client's room: A family member resting in the room is not an incident unless it interferes with care or violates facility policy. This situation is not associated with client harm or safety risk, so it does not meet the criteria for incident reporting.

D. A client's bed alarm is malfunctioning: A malfunctioning bed alarm is a safety issue, particularly for clients at risk of falls. It represents a potential hazard that could lead to client injury, making it necessary to complete an incident report to document the problem and prompt timely intervention or equipment repair.

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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

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Correct Answer is D

Explanation

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