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. Rest in a supine position: Resting in a supine position may compromise lung expansion, and an upright position is often recommended for clients with emphysema to improve ventilation.

b. Breathe in through her nose and out through pursed lips: This technique helps maintain

positive airway pressure, preventing premature airway collapse, and can improve gas exchange in clients with emphysema.

c. Limit fluid intake throughout the day: Adequate hydration is important for maintaining

respiratory secretions in a liquefied state and is generally encouraged for clients with respiratory conditions.

d. Consume a low-protein diet: A low-protein diet is not specifically indicated for improving gas exchange in clients with emphysema. Nutrition recommendations may focus on a well-balanced diet to support overall health.

A. Apply a warm cloth over the client's eyes. B. Place the client in a supine position. C. Maintain seizure precautions. D. Obtain a prescription for an opioid medication for pain.

Correct Answer is C

Explanation

a. Apply a warm cloth over the client's eyes: This intervention is not typically indicated for a client who had a craniotomy. It is important to monitor for signs of increased intracranial pressure, but a warm cloth over the eyes is not a standard intervention.

b. Place the client in a supine position: The position of the client after a craniotomy will depend on the surgeon's preference. It is important to follow specific postoperative positioning

instructions, which may or may not include supine positioning.

c. Maintain seizure precautions: Seizure precautions are crucial for clients who have had a craniotomy, as they are at an increased risk of seizures postoperatively.

d. Obtain a prescription for an opioid medication for pain: Pain management is important, but opioid medications may be carefully titrated due to the potential for respiratory depression and other side effects. It is not the primary intervention in the immediate postoperative period.

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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 on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in theteaching?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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