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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A
24-hour food recall, food preferences, and allergies is incorrect. While these factors are important for understanding the client's dietary habits and possible dietary restrictions, they do not directly provide information about the client's current nutritional status or overall nutritional health.
Choice B
Body mass index (BMI) and serum albumin level is correct. Body mass index (BMI) and serum albumin level are commonly used parameters to assess a client's nutritional status. These measures provide valuable information about the client's weight, muscle mass, and protein status. Let's break down the options:
Choice C
Triceps skin fold and mid-arm circumference is incorrect. These measurements can provide information about the client's body composition and muscle mass. However, they are not as commonly used as BMI and serum albumin level for assessing nutritional status.
Choice D
Weight loss history and body surface area (BSA) is incorrect. Weight loss history is relevant for understanding changes in the client's weight over time, which can indicate potential malnutrition. However, it's not as comprehensive as BMI, which considers both weight and height. Body surface area (BSA) is not typically used to assess nutritional status.
Correct Answer is B
Explanation
Choice A
Describing the value of eating smaller portion sizes is not appropriate. While portion control is important, this advice alone might not address the overall dietary quality and exercise component necessary for effective weight loss.
Choice B
Encouraging a well-balanced diet and moderate exercise is appropriate. This intervention focuses on promoting healthy and sustainable weight loss. A well-balanced diet helps ensure that the client is getting all the necessary nutrients while aiming for a calorie deficit for weight loss. Moderate exercise complements dietary changes and contributes to overall health and weight management.
Choice C
Exploring the reasons, the client wants to lose weight is inappropriate. While understanding the client's motivations is valuable, this doesn't directly provide guidance on how to achieve the goal of losing 10 pounds.
Choice D
Determining if the client has a history of anorexia is inappropriate. While assessing for eating disorders is important in general, assuming there's no indication of anorexia, the focus should be on providing guidance for safe and effective weight loss.
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