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 into the box on the right, placing them in the order of performance. Use all the steps.)
Apply clean gloves.
Ask the client to take a deep breath.
Instill 50 mL of air into the tube.
Pinch and withdraw the tube.
Disconnect the tube from the suction device.
The Correct Answer is E,C,B,D,A
E. Disconnect the tube from the suction device:
Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.
C. Instill 50 mL of air into the tube:
Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.
B. Ask the client to take a deep breath:
Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.
D. Pinch and withdraw the tube:
Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.
A. Apply clean gloves:
Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Decreasing the volume on the hearing aid is correct. Whistling or feedback in a hearing aid can often occur due to excessive volume. Lowering the volume can help eliminate or reduce the whistling sound without disrupting the functioning of the hearing aid.
Choice B Reason:
Cleaning the hearing aid with isopropyl alcohol is incorrect. While cleaning the hearing aid is essential for maintenance, using isopropyl alcohol might not resolve the issue of whistling. It's more for general hygiene and cleanliness of the device.
Choice C Reason:
Turning the hearing aid off for 5 minutes is incorrect. Turning off the hearing aid might not address the specific issue of whistling. Additionally, it could inconvenience the client's ability to hear during that time.
Choice D Reason:
Soaking the hearing aid in warm water is incorrect. Soaking a hearing aid in water is not a recommended method, as it could damage the device and its electronic components. Water exposure might also worsen the issue instead of resolving it.
Correct Answer is A
Explanation
Choice A Reason:
Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.
Choice B Reason:
Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.
Choice C Reason:
Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.
Choice D Reason:
Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.
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