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. Low BP and low pulse rate: In hypovolemic shock, there is a decrease in blood volume,

leading to low blood pressure. However, the body compensates by increasing the heart rate to maintain perfusion to vital organs.

b. Low BP and high pulse rate: This is indicative of hypovolemic shock. The low blood pressure results from decreased blood volume, while the high pulse rate is a compensatory mechanism to maintain cardiac output.

c. High BP and low pulse rate: This combination is not typical of hypovolemic shock. High blood pressure is not expected in the presence of decreased blood volume.

d. High BP and high pulse rate: While a high pulse rate is expected in hypovolemic shock, high blood pressure is not a characteristic finding.

A. Pleural friction rub B. Fine rales C. Rhonchi D. Expiratory wheeze

Correct Answer is D

Explanation

a. Pleural friction rub: Pleural friction rub is a grating sound heard during inspiration and

expiration and is associated with inflammation of the pleura. It is not typically associated with asthma exacerbation.

b. Fine rales: Fine rales (crackles) are usually heard during inspiration and can be associated with conditions such as pneumonia or pulmonary fibrosis. They are not the typical lung sounds in

asthma exacerbation.

c. Rhonchi: Rhonchi are low-pitched wheezes heard during inspiration and expiration. While they can be associated with asthma, expiratory wheezes are more specific to asthma

exacerbation.

d. Expiratory wheeze: Expiratory wheezes are high-pitched, musical sounds heard during

expiration and are characteristic of asthma exacerbation. They result from narrowed airways and increased airway resistance.

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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

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Correct Answer is D

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