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 C
Explanation
A) "We will use an electric blanket to keep your partner warm." - While maintaining warmth is important, this statement does not address communication or understanding between the partner and the client.
B) "Encourage your partner to eat three large meals each day." - Encouraging large meals may not be appropriate for a client at end-of-life care, and this statement doesn't address communication either.
C) "Assume your partner can hear you, even if they do not respond." - This statement acknowledges the importance of communication and connection with the client, even if they are not responsive.
D) "Opioids will be restricted if your partner develops respiratory distress." - This statement may be relevant in certain contexts but is not as directly related to communication and support for the partner.
Correct Answer is D
Explanation
A. “I’ll keep the height of my walker adjusted so lean slightly forward,”- Leaning slightly forward can compromise balance and stability, increasing the risk of falls.
B. “I’ll slide the walker and move it about a foot in front of me.”- Sliding the walker too far ahead can lead to instability and loss of balance.
C. “I’ll move the walker and my stronger leg ahead at the same time- The walker should be moved one step ahead followed by the weaker leg, which should be placed in the middle of the walker.
D. “I’ll keep my elbows slightly bent when I grasp the walker"- Keeping the elbows slightly bent is a general instruction for using a walker which ensures proper posture and balance.
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