A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

"Raise the index finger if gagging occurs during insertion."

"Bear down during insertion."

Say "stop" if a burning sensation is felt inside the nose."

Inhale forcefully during insertion."

Answer and Explanation

The Correct Answer is C

A.   Raising the index finger is not a typical response for managing gagging during NG tube insertion.

B.   Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C.   Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D.   Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.

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Correct Answer is C

Explanation

A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.

C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.

A. "I am trying to understand why this had to happen to me." B. "I dread going to therapy, but I am getting comfortable with my prosthesis." C. "My leg looks a little red, but my doctor says it's healing well." D. "I may be ready to talk about my leg in a week or so."

Correct Answer is B

Explanation

A. Expressing a desire to understand why the amputation happened suggests the client is still grappling with acceptance.
B. Expressing discomfort with therapy but being comfortable with the prosthesis indicates an acknowledgment of the loss and adaptation to the situation.
C. Noting the leg's appearance and healing is an observation but does not necessarily indicate acceptance.
D. Indicating a readiness to talk about the leg in a week or so suggests the client is not currently ready to discuss or fully accept the loss.

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A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

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