A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)
Pinch and withdraw the tube.
Disconnect the tube from the suction device.
Instill 50 mL of air into the tube.
Ask the client to take a deep breath.
Apply clean gloves.
The Correct Answer is E,B,C,D,A
First, the nurse should apply clean gloves (E) to maintain sterility and safety. Next, the nurse should disconnect the tube from the suction device (B), ensuring that the device is no longer actively working on the tube.
Before removing the tube, it is important to instill air into it (C); this helps clear any residual contents and minimizes the risk of aspiration. The nurse should then ask the client to take a deep breath (D), which helps close the epiglottis to prevent aspiration during the removal of the tube. Finally, the nurse can pinch and withdraw the tube (A), completing the process in a swift, steady motion to ensure comfort and safety for the client.
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Related Questions
Correct Answer is B
Explanation
A. The nurse should stand on the client’s weaker side (left side) to provide support and stability during the transfer. Standing on the stronger side offers less assistance and increases the risk of falls.
B. When assisting a client with left-sided weakness to transfer from bed to chair, the nurse should use proper body mechanics to protect both the client and self.Flexing the hips and knees allows the nurse to use the leg muscles (strongest muscles) rather than the back, reducing risk of injury. This position also provides stability and balance, allowing controlled movement as the client stands.
C. Raise the bed to waist level before moving the client- Adjusting the bed height can facilitate the transfer process, but it is not directly related to the client's left-sided weakness.
D. Pivot on the foot farthest from the bed when assisting the client into the chair- Pivoting on the foot farthest from the bed allows for a smooth and controlled transfer motion but does not address the client's left-sided weakness specifically.
Correct Answer is C
Explanation
A. Drink citrus juice with meals: Citrus juice may irritate the bladder and worsen urinary incontinence symptoms.
B. Train the bladder by voiding every 5 hr: Voiding on a schedule may help manage urinary incontinence, but the specific interval should be determined based on individual needs, not a fixed timeframe like every 5 hours.
C. Perform pelvic-muscle exercises: Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that control urination, improving urinary continence.
D. Apply adult diapers at bedtime: While using protective garments may be necessary for managing urinary incontinence, it does not address the underlying issue or provide potential improvement.
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