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 D
Explanation
Correct answer: D
Choice A
Urinary ketones are not most important. Monitoring urinary ketones can provide information about the utilization of glucose and fat as energy sources. However, it is not the primary lab value to monitor in TPN administration.
Choice B
Serum protein is not most important. Monitoring serum protein levels is important to assess nutritional status, but it might not be as immediate a concern as serum osmolarity.
Choice C
Serum osmolarity reflects the concentration of particles (such as electrolytes, glucose, and other solutes) in the blood. Monitoring serum osmolarity is importantto prevent complications related to fluid and electrolyte imbalances that can arise from the administration of TPN.Blood glucose levels (option D) are more critical because TPN can significantly impact glucose metabolism
Choice D
When caring for a client receiving total parenteral nutrition (TPN), the nurse’spriorityis tomonitor blood glucose levels. TPN can affect blood glucose, and observing for signs of hyperglycemia or hypoglycemia is crucial.Additionally, administering insulin as directed based on blood glucose levels is essential.
Correct Answer is C
Explanation
Choice A
Providing pamphlets about heart-healthy diet selections should not be implemented. Providing information is important, but it might not be as effective if the client is strongly resistant. Engaging in a conversation first can help tailor the information to the client's needs.
Choice B
Referring the client to a dietitian for nutrition education should not be implemented. A dietitian can provide valuable education, but it might be more beneficial to address the client's concerns and resistance before making the referral.
Choice C
Discussing client's concerns about the change in diet should be implemented. When a client is resistant or unwilling to make changes to their diet and lifestyle, it's important for the nurse to engage in open and empathetic communication. Option C, discussing the client's concerns about the change in diet, is the most appropriate initial response.
By engaging in a conversation with the client, the nurse can better understand the client's perspective, reasons for resistance, and potential barriers to making dietary changes. This approach allows the nurse to address the client's concerns, provide information, and work collaboratively to find solutions that might be more acceptable to the client.
Choice D
Suggesting exercise as an alternative to increase HDL levels should not be implemented. Exercise is important for heart health, but it's important to address the client's resistance to dietary changes first. Additionally, dietary changes and exercise can work together to improve overall heart health.
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