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. 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.
Correct Answer is D
Explanation
A. “I will notify my provider before taking any other medications.” - This statement reflects an understanding of the need to check for potential interactions with other medications, which is an appropriate response.
B. “I have made an appointment to see my dentist next week.” - Dental care is important, and
scheduling an appointment with the dentist is a responsible action. However, it does not indicate a misunderstanding about the medication.
C. “I will take this medication with meals.” - Taking phenytoin with meals is a correct instruction as it can help reduce gastrointestinal side effects.
D. "I'll be glad when my seizures stop so I can quit taking this medicine." - This statement
indicates a misunderstanding about the chronic nature of anti-seizure medications. The client needs further education on the importance of continuing the medication even if seizures stop.
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