A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

Verify the provider’s prescription to discontinue the tube.

Disconnect the tube from the wall suction.

Perform hand hygiene.

Provide mouth care to the client.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The first step in removing an NG tube is to verify the provider’s prescription to discontinue the tube. This ensures that the removal is authorized and appropriate for the client’s current condition.

Choice B reason:

Disconnecting the tube from the wall suction is an important step, but it should be done after verifying the provider’s prescription. This step prevents any suction-related complications during the removal process.

Choice C reason:

Performing hand hygiene is crucial to prevent infection, but it is not the first step. Hand hygiene should be performed after verifying the provider’s prescription and before touching the client or any equipment.

Choice D reason:

Providing mouth care to the client is important for comfort and hygiene, but it is not the first step in the process of removing an NG tube. This can be done after the tube has been safely removed.

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Correct Answer is B

Explanation

Choice A reason:

Akathisia: Akathisia is characterized by a feeling of inner restlessness and an inability to stay still. It often manifests as constant movement, such as pacing or fidgeting. While akathisia is a common side effect of antipsychotic medications, it does not typically involve involuntary movements of the tongue and face.

Choice B reason:

Tardive dyskinesia: Tardive dyskinesia is a serious and often irreversible side effect of long-term antipsychotic use, including chlorpromazine. It is characterized by involuntary, repetitive movements, particularly of the face, tongue, and jaw. These movements can include lip smacking, tongue protrusion, and grimacing. This condition is a result of prolonged dopamine receptor blockade in the brain.

Choice C reason:

Dystonia: Dystonia involves sustained muscle contractions that cause twisting and repetitive movements or abnormal postures. It can affect any part of the body, including the neck, face, and limbs. While dystonia can be a side effect of antipsychotic medications, it typically presents as muscle spasms rather than the repetitive, involuntary movements seen in tardive dyskinesia.

A. Painful urination B. Urge incontinence C. Critically elevated prostate-specific antigen (PSA) level D. Difficulty starting the flow of urine

Correct Answer is D

Explanation

Choice A reason: Painful urination

Painful urination, or dysuria, is not a typical symptom of benign prostatic hyperplasia (BPH). BPH primarily affects the flow of urine due to the enlargement of the prostate gland, which can obstruct the urethra. While BPH can cause discomfort, it does not usually result in painful urination. Painful urination is more commonly associated with urinary tract infections (UTIs) or other conditions affecting the urinary tract.

Choice B reason: Urge incontinence

Urge incontinence, characterized by a sudden and intense urge to urinate followed by involuntary loss of urine, can occur in some cases of BPH but is not the most common symptom. BPH typically causes symptoms related to urinary obstruction, such as difficulty starting urination, weak urine stream, and incomplete bladder emptying. Urge incontinence may develop if the bladder becomes overactive due to the obstruction, but it is not a primary symptom.

Choice C reason: Critically elevated prostate-specific antigen (PSA) level

While an elevated prostate-specific antigen (PSA) level can be associated with BPH, it is not a definitive finding. PSA levels can be elevated due to various conditions, including prostate cancer, prostatitis, and BPH. However, a critically elevated PSA level is more concerning for prostate cancer rather than BPH. Therefore, while PSA testing is useful in the evaluation of prostate conditions, it is not specific to BPH.

Choice D reason: Difficulty starting the flow of urine

Difficulty starting the flow of urine, also known as hesitancy, is a hallmark symptom of BPH. The enlarged prostate gland can compress the urethra, making it difficult for urine to pass through. This can lead to a weak urine stream, straining to urinate, and a feeling of incomplete bladder emptying. These symptoms are collectively known as lower urinary tract symptoms (LUTS) and are commonly associated with BPH.

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A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

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Correct Answer is B

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Correct Answer is D

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