A nurse is preparing to remove an NG tube for a patient.
Which of the following actions should the nurse take first?
Perform hand hygiene and don gloves
Verify provider order to discontinue the tube
Observe the amount and color of drainage
Disconnect the tube from the wall suction .
The Correct Answer is B
The correct answer is Choice B.
Step 1 is to verify the provider’s order to discontinue the tube. It is crucial to ensure that the removal of the NG tube is in accordance with the provider’s orders before proceeding with the removal process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Daily measurement of abdominal girth is crucial in patients with an intestinal obstruction undergoing continuous gastrointestinal decompression. This is because any changes in the abdominal girth can indicate an improvement or worsening of the obstruction. Regular monitoring allows for timely intervention and adjustment of the care plan.
Choice B rationale
Maintaining the patient in Fowler’s position can help promote the drainage of gastric contents via the nasogastric tube. This position, where the patient is seated in bed at an angle of 45-60 degrees, uses gravity to assist in the drainage process, thereby potentially alleviating discomfort and reducing the risk of aspiration.
Choice C rationale
Moistening the patient’s lips with lemon glycerin swabs is not recommended. While it’s important to keep the patient’s lips moist to prevent dryness and cracking due to the nasogastric tube, lemon glycerin swabs can potentially dry out the lips more and cause irritation.
Choice D rationale
Using sterile water to irrigate the nasogastric tube is a standard practice in managing patients with a nasogastric tube. This helps ensure the patency of the tube and prevent blockages, allowing for effective gastrointestinal decompression.
Correct Answer is B
Explanation
Choice A rationale
Skin pallor and cool-to-touch skin are common signs of severe dehydration. When the body is severely dehydrated, blood flow to the skin decreases, causing the skin to feel cool and look pale.
Choice B rationale
Pitting edema is not a clinical finding of severe dehydration. In fact, it’s quite the opposite. Pitting edema is a condition that causes swelling due to fluid accumulation, often due to conditions like heart failure, liver disease, or kidney disease.
Choice C rationale
Tachycardia with a thready pulse is a common sign of severe dehydration. The heart rate increases in an attempt to maintain blood flow to the organs, and the pulse may feel weak or thready due to low blood volume.
Choice D rationale
Lung sounds diminished with crackles upon auscultation is not typically associated with dehydration. This is more commonly seen in conditions affecting the lungs such as pneumonia or heart failure.
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