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 A
Explanation
a. Serum potassium: Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias.
b. Serum amylase: This is not directly related to furosemide therapy. Amylase is an enzyme associated with pancreatic and salivary function.
c. Serum triglyceride: Furosemide does not typically have a direct impact on serum triglyceride levels.
d. Serum cholesterol: Furosemide does not typically have a direct impact on serum cholesterol levels.
Correct Answer is A
Explanation
a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a
potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.
b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to
treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.
c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.
d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.
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