A nurse is preparing to insert a nasogastric tube in a client. Which of the following actions should the nurse take?

Encourage client to swallow while advancing tube

Measure the length of the tube from client's nose to shoulder

Place client in semi-Fowler's position in bed

Advance tube during client's inspiration

Answer and Explanation

The Correct Answer is A

Rationale:

A. Encourage client to swallow while advancing tube: Swallowing facilitates the passage of the nasogastric tube through the oropharynx and esophagus by closing the epiglottis and reducing the risk of the tube entering the trachea. This action helps guide the tube smoothly into the stomach.

B. Measure the length of the tube from client's nose to shoulder: Proper measurement involves extending the tube from the nose to the earlobe and then down to the xiphoid process, not just to the shoulder.

C. Place client in semi-Fowler's position in bed: The client should be placed in a high-Fowler’s position, not semi-Fowler’s, to promote comfort and reduce the risk of aspiration. This upright position also allows for easier passage of the tube through the upper GI tract.

D. Advance tube during client's inspiration: Advancing the tube during inspiration increases the risk of the tube entering the airway rather than the esophagus. The tube should be advanced when the client is swallowing, which helps direct it into the digestive rather than respiratory tract.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. "Perform sponge baths until the baby's umbilical cord falls off.": This is the appropriate instruction because keeping the umbilical stump dry reduces the risk of infection and promotes natural detachment. Sponge baths help prevent water from soaking the cord area until it fully heals and separates.

B. "Use an alkaline soap to bathe the baby.": Alkaline soaps can irritate a newborn’s sensitive skin by disrupting the natural acidic pH balance. Mild, pH-neutral or hypoallergenic baby cleansers are recommended to maintain skin integrity.

C. "Ensure the bath water is at least 96 degrees Fahrenheit.": Bath water should be warm, around 98.6°F (37°C), which is close to body temperature. Setting a minimum like 96°F may be too low and uncomfortable, while overheating the water poses a burn risk.

D. "Apply talcum powder daily after bathing in order to prevent diaper rash.": Talcum powder is not recommended due to the risk of respiratory irritation if inhaled. Preventing diaper rash is better achieved through frequent diaper changes and the use of barrier creams.

A. Tilt the client's head forward during meals. B. Encourage socialization during meal times. C. Elevate the head of the client's bed to 30", D. Provide three large meals per day.

Correct Answer is A

Explanation

Rationale:

A. Tilt the client's head forward during meals: Tilting the head forward, also known as the chin-tuck technique, helps close the airway and reduce the risk of aspiration in clients with dysphagia. This position facilitates safer swallowing by improving bolus control and airway protection.

B. Encourage socialization during meal times: While social interaction is generally beneficial, clients with dysphagia require focused attention during meals to prevent choking or aspiration. Distractions can compromise concentration on swallowing techniques and safety precautions.

C. Elevate the head of the client's bed to 30": Although elevating the head of the bed helps reduce aspiration risk, a 30" elevation is not optimal for swallowing. A 45–90 degree upright position is typically recommended during meals to support safer swallowing mechanics.

D. Provide three large meals per day: Clients with dysphagia benefit more from small, frequent meals to reduce fatigue and lower the risk of aspiration. Large meals can overwhelm their ability to chew and swallow safely, increasing the risk of complications.

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A nurse is preparing to insert a nasogastric tube in a client. Which of the following actions should the nurse take?

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