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

Beef broth should not be omitted. Generally, clear broths like beef broth are lower in fat and may be a better choice for someone with cholelithiasis compared to creamy or fatty foods.

Choice B

Ketchup should not be omitted. Ketchup is not typically high in fat and may not be a significant concern for someone with cholelithiasis.

Choice C

Ice cream should be omitted. Cholelithiasis refers to the presence of gallstones in the gallbladder. Gallstones can form from substances in the bile, and certain foods can trigger symptoms in individuals with gallbladder issues. One of the common triggers is high-fat foods, which can cause the gallbladder to contract and potentially lead to pain or discomfort.

Choice D

Bread should not be omitted. While bread contains some fat, it's not as high in fat as ice cream. The focus for individuals with cholelithiasis is often on high-fat foods rather than moderate-fat foods like bread.

A. Opened package of hot dogs. B. Packaged of uncooked lamb chops. C. Opened package of deli sliced meats. D. Ground-up hamburger raw meat.

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.

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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

A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal. What food choice should the nurse encourage the client to omit?

Correct Answer is C

Explanation

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

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