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
Client with a nasogastric tube to low, intermittent suction is not correct. While there is a risk of aspiration with a nasogastric tube in place, the tube is intended to help drain stomach contents, reducing the risk of aspiration. However, if the tube is not properly positioned or managed, there could still be some risk.
Choice B
Client who has sensory aphasia and is receiving a clear liquid diet is correct. Sensory aphasia refers to a language disorder that affects a person's ability to understand language and communication. This client may have difficulty swallowing safely and effectively, which increases the risk of aspiration. Additionally, a clear liquid diet consists of thin liquids that are more likely to be aspirated compared to thicker fluids.
Choice C
Client receiving 30% oxygen via a non-rebreather face mask is not correct. Oxygen therapy can increase the risk of drying the airways and potentially increasing the risk of aspiration, but if the oxygen mask is properly fitted and humidified, the risk may be minimized.
Choice D
Client experiencing dysphagia who is prescribed a full liquid diet is not correct. Dysphagia refers to difficulty swallowing, which can increase the risk of aspiration. However, a full liquid diet includes thicker liquids that are less likely to be aspirated compared to thin liquids. Still, the risk of aspiration exists, especially if the client has severe dysphagia.
Correct Answer is A
Explanation
Choice A
Body mass index (BMI) of 17 is the correct finding. A low Body Mass Index (BMI) is a common indicator of malnutrition. BMI is a measurement that considers a person's weight in relation to their height. A BMI of 17 suggests that the person is underweight, which can be indicative of malnutrition. Malnutrition is characterized by inadequate intake of calories, protein, vitamins, and minerals that are essential for maintaining health and well-being.
Choice B
Decrease in appetite is not correct finding. While a decrease in appetite might contribute to malnutrition, it's a symptom rather than a definitive indicator.
Choice C
Dry mucosal membranes are not the correct finding. Dry mucosal membranes can be related to dehydration or other conditions, but they are not specific enough to confirm malnutrition on their own.
Choice D
Weight of 227 pounds (103 kg) is not the correct finding. This weight is not necessarily indicative of malnutrition on its own. It's important to consider the individual's height, BMI, and other factors when assessing malnutrition.
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