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.

Answer and Explanation

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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Correct Answer is B

Explanation

A) Administering vaginal cream to a client who has a vaginal infection - This task involves administration of medication, which typically falls within the scope of licensed nursing practice.

B) Providing postmortem care for a client who has just died - When delegating tasks to assistive personnel, nurses can assign activities such as providing postmortem care.
C) Suctioning a tracheostomy for a client who has a recent head injury - Suctioning a tracheostomy requires specialized training and is typically performed by licensed nursing staff.
D) Changing a peripheral IV dressing for a client who is postoperative - Changing an IV dressing is a task that require skills of a licensed nurse hence cannot be delegated to an assistive personnel.

A. Tell the client to think about something else. B. Ask the client to describe their support system. C. Ask the client why they're unable to cope. D. Tell the client that everything will be okay.

Correct Answer is B

Explanation

A) Tell the client to think about something else. - This response dismisses the client's feelings and does not address the underlying issue of coping with job loss.
B) Ask the client to describe their support system. - This action allows the nurse to assess the resources available to the client for coping with stress and provides an opportunity to explore potential sources of support.
C) Ask the client why they're unable to cope. - While understanding the reasons behind the client's inability to cope is important, this question may come across as judgmental or dismissive of the client's feelings.

D) Tell the client that everything will be okay. - While offering reassurance is important, it should be done in the context of acknowledging the client's feelings and exploring coping strategies.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is B

Explanation

A nurse is collecting data from a client who reports an inability to cope because of their recent job loss. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?

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