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 D

Explanation

A) Use a narrower cuff to repeat the BP measurement. - Using a narrower cuff is not appropriate and may result in inaccurate BP readings.
B) Request a prescription for an antihypertensive medication. - This action is premature based on a single elevated BP reading and should be guided by the provider's assessment and recommendations.
C) Deflate the cuff faster when repeating the BP measurement. - The speed of cuff deflation does not significantly affect BP measurement accuracy, and this action may not address the underlying cause of the elevated BP.
D) Measure the client's BP in the other arm. - Confirming the elevated BP with a reading from the other arm can help determine if the elevation is due to positioning or equipment error.

A. Ask the client to state their room number. B. Have the client state their phone number. C. Review the client's photograph in the medical record. D. Request an assistive personnel to identify the client.

Correct Answer is C

Explanation

A) Ask the client to state their room number. - Clients with advanced dementia may not reliably remember their room number, and this method may not accurately verify their identity.
B) Have the client state their phone number. - Clients with advanced dementia may not remember their phone number, and it may not be an effective method of identification.
C) Review the client's photograph in the medical record. - Reviewing the client's photograph in the medical record is a reliable way to verify their identity, especially if they do not have an identification band.
D) Request an assistive personnel to identify the client. - While assistive personnel may recognize the client, it's important for the nurse to verify identity through official documentation such as the medical record.

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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 on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification and. Which of the following actions should the nurse take to verify the client's identity?

Correct Answer is C

Explanation

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