he nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Instruct the client to place his chin to his chest and swallow.

Withdraw the tube if the client gags during insertion.

Place the client in a supine position.

Measure the tube for insertion from the tip of the nose to the umbilicus.

Answer and Explanation

The Correct Answer is A

a. Instruct the client to place his chin to his chest and swallow: This technique helps facilitate the passage of the nasogastric tube through the pharynx and into the esophagus.

b. Withdraw the tube if the client gags during insertion: Gagging is a normal response, and

withdrawing the tube may lead to repeated attempts and discomfort for the client. Encouraging the client to swallow can help overcome the gag reflex.

c. Place the client in a supine position: The client is usually positioned in a semi-Fowler's position or upright to ease tube insertion and minimize the risk of aspiration.

d. Measure the tube for insertion from the tip of the nose to the umbilicus: The proper

measurement for nasogastric tube insertion is typically from the tip of the nose to the earlobe and then down to the xiphoid process, not the umbilicus.

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Correct Answer is A

Explanation

a. Determine the patency of the tubing: The first action should be to assess for any obstruction or kinks in the tubing. A blockage may be preventing the flow of urine.

b. Notify the provider: While notifying the provider may be necessary, assessing the tubing for patency is a more immediate action.

c. Offer oral fluids: While hydration is important, the priority is to ensure that the urinary catheter is functioning properly.

d. Administer a prescribed analgesic: Pain management is important postoperatively, but the

immediate concern is the lack of urinary output, which requires assessment and intervention to rule out catheter obstruction.

A. Begin oxygen therapy. B. Start an IV infusion of lactated Ringer’s. C. Initiate cardiac monitoring. D. Administer IV morphine.

Correct Answer is A

Explanation

a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.

b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.

c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.

d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.

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he nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?

Correct Answer is A

Explanation

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