The charge nurse observes a newly hired nurse who is preparing to insert a nasogastric tube. Which action by the charge nurse takes priority?

Demonstrate correct measurement of the tube insertion length.

Remind the nurse to apply lubricant to the tube before insertion.

Confirm that the nurse has auscultated the client's bowel sounds.

Elevate the head of the bed before the nurse inserts the tube.

Answer and Explanation

The Correct Answer is A

Choice A

Demonstrating correct measurement of the tube insertion length is the first priority. Inserting a nasogastric tube to the appropriate length is crucial for ensuring that the tube reaches the stomach and is not inserted too far. Incorrect insertion length can lead to complications, discomfort, or potential harm to the patient. Therefore, demonstrating and ensuring the correct measurement of the tube insertion length takes priority.:

Choice B

Reminding the nurse to apply lubricant to the tube before insertion is not first priority. Applying lubricant helps ease the insertion process, but it is not the most critical step to prioritize initially.

Choice C

Confirming that the nurse has auscultated the client's bowel sounds is not the first priority. Bowel sounds assessment is important to ensure proper placement, but this step can be done after ensuring the correct measurement of the insertion length.

Choice D

Elevating the head of the bed before the nurse inserts the tube is not the first priority: Elevating the head of the bed helps facilitate the passage of the tube into the stomach, but it is not the first priority in this context.

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Correct Answer is C

Explanation

Choice A

Opened package of hot dogs is not correct. Hot dogs are processed and often contain preservatives that help extend their shelf life. However, it's still important to follow proper storage guidelines to ensure their safety.

Choice B

Packaged of uncooked lamb chops is not correct. Uncooked meats are generally safe if stored properly. The main concern arises when cooking and handling them, as raw meats can potentially cross-contaminate other foods if proper sanitation measures are not followed.

Choice C

Opened package of deli sliced meat is correct. Among the options provided, an opened package of deli sliced meats (option C) is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40°F (4.4°C) or below for more than two days.

Deli sliced meats are considered a high-risk food for bacterial growth and foodborne illnesses. When meats are sliced and exposed to air, they have a larger surface area, making them more susceptible to bacterial contamination. While the refrigerator temperature of 40°F (4.4°C) helps slow down bacterial growth, it doesn't completely prevent it, especially if the food has been stored for an extended period of time.

Choice D

Ground-up hamburger raw meat is not correct. Similar to uncooked lamb chops, raw ground meat is generally safe when stored properly and handled with care. However, ground meats do have a larger surface area that can allow bacteria to grow more easily, which is why safe cooking practices are important.

A. Explain the benefits of a high fibre diet. B. Confirm that these foods should be avoided. C. Encourage soft foods such as yogurt. D. Suggest that the client also avoid fruit skins.

Correct Answer is B

Explanation

Choice A

Explain the benefits of a high fibre diet is not correct response. While a high fibre diet can indeed be beneficial for individuals with haemorrhoids by promoting regular bowel movements and reducing strain during defecation, the immediate concern here is addressing the client's understanding about avoiding nuts and seeds. This information could be provided as a follow-up after confirming the client's understanding in response to option B.

Choice B

Confirm that these foods should be avoided is the correct response. In this situation, the nurse's first response should be to confirm the client's understanding and provide accurate information about the need to avoid certain foods. Nuts and seeds can be challenging to digest and may lead to irritation and inflammation in individuals with haemorrhoids. Confirming the client's understanding and providing guidance aligns with the nurse's role in patient education and care.

Choice C

Encourage soft foods such as yogurt is not the correct response. Encouraging soft foods like yogurt is a reasonable suggestion for someone with haemorrhoids, as soft foods are generally easier to digest and less likely to cause irritation. However, the client's statement was specifically about avoiding nuts and seeds. While this choice might be relevant, it doesn't directly address the client's statement.

Choice D

Suggest that the client also avoid fruit skins is not the correct response. This option is not directly related to the client's concern about nuts and seeds. Fruit skins generally contain dietary fibre, which can be beneficial for maintaining regular bowel movements. While some individuals might find that certain fruits with tough skins could exacerbate their haemorrhoid symptoms, this advice might be better suited for a separate discussion about dietary choices rather than as a direct response to the client's statement.

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The charge nurse observes a newly hired nurse who is preparing to insert a nasogastric tube. Which action by the charge nurse takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a food safety educational class for a group of parents. Which type of food is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40°F (4.4°C) or below for more than two days?

Correct Answer is C

Explanation

A female client with haemorrhoids tells the nurse that she understands the need to avoid eating nuts and seeds to prevent inflammation. How should the nurse respond?

Correct Answer is B

Explanation

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