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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Correct Answer is A

Explanation

Rationale:

A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.

B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.

C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.

D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.

A. "This medication prevents your baby from developing jaundice." B. "This medication prevents your baby from developing bleeding problems." C. "This medication enhances regulation of your baby's temperature." D. "This medication enhances your baby's immune response."

Correct Answer is B

Explanation

Rationale:

A. "This medication prevents your baby from developing jaundice.": Phytonadione (vitamin K) does not play a role in bilirubin metabolism or the prevention of jaundice. Jaundice results from immature liver function and increased bilirubin levels, unrelated to vitamin K activity.

B. "This medication prevents your baby from developing bleeding problems.": Phytonadione is given to newborns to promote clotting factor synthesis and reduce the risk of hemorrhagic disease of the newborn. Newborns have low vitamin K stores at birth, making supplementation essential for preventing bleeding disorders.

C. "This medication enhances regulation of your baby's temperature.": Thermoregulation in newborns is managed by external warming and metabolic processes, not by vitamin K. Phytonadione has no impact on temperature control or thermal stability.

D. "This medication enhances your baby's immune response.": Vitamin K does not affect immune function. Its role is in coagulation, not immune system development or enhancement, and therefore does not influence infection prevention or immune strength.

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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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