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 C

Explanation

a. Allow the client to take her morning vitamins: This is generally acceptable unless there are specific preoperative instructions regarding medication.

b. Allow the client to keep her tongue stud in: Metallic objects, including tongue studs, are

usually removed before surgery to prevent interference with equipment and to ensure patient safety.

c. Allow the client to keep her hearing aids in: It is important for the client with a hearing

impairment to keep hearing aids in place to facilitate communication and maintain awareness of the environment.

d. Allow the client to consume clear liquids up to the time of surgery: Clear liquids are typically restricted before surgery to prevent aspiration. This action may not align with standard

preoperative fasting guidelines.

A. Decreased calcium level B. Decreased potassium level C. Elevated magnesium level D. Elevated sodium level

Correct Answer is B

Explanation

a. Decreased calcium level: NG tube drainage is more likely to result in hypokalemia (decreased potassium) than hypocalcemia (decreased calcium).

b. Decreased potassium level: NG tube drainage, which contains stomach contents, can lead to loss of potassium. Monitoring for hypokalemia is crucial as it can result in cardiac dysrhythmias.

c. Elevated magnesium level: NG tube drainage is not typically associated with an increase in magnesium levels.

d. Elevated sodium level: NG tube drainage may contribute to sodium loss, leading to hyponatremia, rather than hypernatremia.

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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

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