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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Place an identification tag on the outside of the client's shroud. - This is an important step in maintaining proper identification of the deceased individual.
B) Remove the client's dentures and give them to the client's family. - Dentures should be left in place unless requested by the family, as they are considered part of the deceased individual's personal belongings.
C) Wear sterile gloves when cleaning the client's body. - Sterile gloves are not necessary for postmortem care unless there are specific infection control concerns.
D) Ask the assistive personnel to document the client's time of death. - Documenting the time of death is typically the responsibility of the nurse or provider, not the assistive personnel.
Correct Answer is B
Explanation
A. Assign different nurses to provide care for clients each day- Continuity of care is important for building rapport and trust between clients and their healthcare providers.
B. Restrict the number of visitors for clients- Limiting visitors can help reduce noise and stress for clients, promoting rest and recovery.
C. Offer the clients many choices regarding care- While autonomy is important, offering too many choices can be overwhelming for clients, especially in a stressful environment like an acute care unit.
D. Turn on loud music in client care areas- Loud music can increase stress and discomfort for clients, especially those who are trying to rest or recover.
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