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: While some women may start producing milk as early as 24 to 48 hours after delivery, this is not the typical timeframe for most women. The initial milk produced is colostrum, which is different from the mature milk that comes in later.

Choice B reason: For most women, breast milk “comes in” around 3 to 5 days postpartum. This period marks the transition from colostrum to mature milk, which is more abundant and nutritionally rich. During this time, mothers may experience breast engorgement and increased milk production.

Choice C reason:

Breast milk typically does not take about 10 days to come in. By this time, most women will have already transitioned to mature milk. If milk production has not started by this time, it may indicate a problem that requires medical attention.

Choice D reason:

The timeframe of 6 to 8 days is also not typical for the initial onset of mature milk production. Most women will have their milk come in within the first week postpartum.

A. Stop taking the pills and switch to a different contraceptive method. B. Take a home pregnancy test. C. Do not have vaginal intercourse until after your next period. D. Take the missed dose now, then continue the medication as ordered.

Correct Answer is D

Explanation

Choice A reason:

Stop taking the pills and switch to a different contraceptive method: This is not necessary for a single missed dose. Stopping the pills entirely and switching methods would be an overreaction and could lead to unnecessary complications. The standard recommendation for a missed dose is to take it as soon as remembered and continue with the regular schedule.

Choice B reason:

Take a home pregnancy test: Taking a home pregnancy test is not required immediately after missing a single dose of oral contraceptives, especially if it is the first week of the cycle. Pregnancy tests are typically recommended if there is a significant delay in the menstrual cycle or if multiple doses are missed.

Choice C reason:

Do not have vaginal intercourse until after your next period: This advice is overly cautious for a single missed dose. While it is important to use backup contraception if multiple doses are missed, abstaining from intercourse until the next period is not necessary for just one missed pill.

Choice D reason:

Take the missed dose now, then continue the medication as ordered: This is the correct course of action. According to guidelines, if a single hormonal pill is missed, it should be taken as soon as possible, and the next pill should be taken at the usual time. This may mean taking two pills in one day, but it ensures continuous contraceptive protection.

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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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