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. Slow: Atrial fibrillation is characterized by an irregular heart rate, but it may not necessarily be slow. The rate can vary, and it is irregularly irregular.

b. Not palpable: While atrial fibrillation can result in an irregularly irregular pulse, it is not necessarily indicative of a pulse that is not palpable.

c. Irregular: Atrial fibrillation is associated with an irregularly irregular pulse due to the chaotic and disorganized atrial activity.

d. Bounding: Bounding pulses are characterized by a forceful and strong pulse, which is not typically associated with atrial fibrillation.

A. Three to seven days after menses stops. B. On the same day every month. C. Prior to the beginning of menses. D. On the second day of menstruation.

Correct Answer is A

Explanation

a. Three to seven days after menses stops: Performing BSE a few days after menstruation allows the breasts to return to a more baseline state, reducing the influence of hormonal changes on

breast tissue.

b. On the same day every month: Hormonal changes during the menstrual cycle can affect breast tissue, and performing BSE on the same day every month may not provide consistent conditions for examination.

c. Prior to the beginning of menses: Hormonal changes before menstruation can lead to breast tenderness and changes, potentially affecting the accuracy of the examination.

d. On the second day of menstruation: Hormonal changes and potential breast tenderness during the early days of menstruation may not be the optimal time for BSE.

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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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