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 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.

A. 24-hour food recall, food preferences, and allergies. B. Body mass index (BMI) and serum albumin level. C. Triceps skin fold and mid-arm circumference. D. Weight loss history and body surface area (BSA).

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.

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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 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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Correct Answer is B

Explanation

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