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 B

Explanation

a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between

inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.

b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.

c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.

d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.

A. Provide humidified oxygen. B. Prelubricate the suction catheter tip with sterile saline when suctioning the airway. C. Perform chest physiotherapy prior to suctioning. D. Hyperventilate the client with 100% oxygen before suctioning the airway.

Correct Answer is A

Explanation

a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin

secretions in a client with a tracheostomy.

b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.

c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.

d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing

humidified oxygen is a more appropriate approach.

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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

A nurse is reinforcing discharge teaching with a client following an episode of statusasthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of theteaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Correct Answer is A

Explanation

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