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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.
b. Body weight: Monitoring body weight before and after hemodialysis provides a direct
measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.
c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.
d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.
Correct Answer is D
Explanation
a. Position the client on the nonoperative side: The client should be positioned on the operative side to facilitate expansion of the remaining lung.
b. Monitor respiratory status every 8 hr: Postoperative respiratory status should be monitored more frequently than every 8 hours to assess for complications, especially in the initial
postoperative period.
c. Elevate the head of the bed to a 15° angle: The head of the bed should be elevated to a higher angle (usually 30-45 degrees) to promote optimal lung expansion and reduce the risk of
complications such as atelectasis.
d. Encourage the client to splint the incision when coughing: Encouraging the client to splint the incision when coughing helps minimize pain and supports effective coughing to prevent
complications such as atelectasis.
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