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 A
Explanation
Choice A
Serum HDL (high-density lipoprotein) of 35 mg/dL (0.91 mmol/L). Among the options provided, a serum HDL level of 35 mg/dL (0.91 mmol/L) is the assessment data that indicates the need for referral to a nutritionist. HDL is often referred to as "good" cholesterol because it helps remove excess cholesterol from the bloodstream, reducing the risk of cardiovascular disease. In this case, the HDL level of 35 mg/dL is below the recommended reference range for females (greater than 55 mg/dL or greater than 0.91 mmol/L), which could suggest a potential need for dietary and lifestyle interventions to improve cardiovascular health.
Choice B
Serum HbA1c (glycosylated haemoglobin) of 4.8% (0.05) is incorrect. This HbA1c level is within the normal reference range (4% to 5.9%) and indicates good blood sugar control.
Choice C
BMI (body mass index) of 22 kg/m² is incorrect. A BMI of 22 is within the normal weight range and might not necessarily indicate the need for a nutritionist referral.
Choice D
Total serum calcium of 10 mg/dL (2.5 mmol/L) is incorrect. This calcium level is within the normal reference range and might not require a nutritionist referral, unless there are other specific concerns related to calcium intake.
Correct Answer is D
Explanation
Choice A
Nuts is incorrect. Nuts are a good source of healthy fats, including monounsaturated and polyunsaturated fats, which can actually have a positive impact on heart health. They have been associated with improving HDL cholesterol levels and can be a part of a heart-healthy diet. While nuts are calorie-dense, small portions can be included as part of the client's diet to replace less healthy snacks. Therefore, nuts might not need to be completely avoided.
Choice B
Shellfish Is incorrect. Shellfish, including shrimp, crab, and lobster, are relatively low in saturated fat and cholesterol. While they do contain cholesterol, dietary cholesterol has less impact on blood cholesterol levels compared to saturated and trans fats. The client's main concern is elevated LDL cholesterol, which is influenced more by saturated fat intake. Therefore, avoiding shellfish might not be as crucial as focusing on saturated fat sources.
Choice C
Eggs is incorrect. Eggs are a source of dietary cholesterol, but they also provide essential nutrients. Recent research suggests that dietary cholesterol from foods like eggs has less impact on blood cholesterol levels for most people than was previously thought. For the client, the more significant concern is the elevated LDL cholesterol level. If the client enjoys eggs, they might not need to completely avoid them, but they should consume them in moderation and consider other dietary changes to reduce saturated fat intake.
Choice D
Cheese is correct. Cheese is often high in saturated fats, which can contribute to elevated LDL cholesterol levels. Therefore, it would be important for the client to limit their intake of high-fat cheeses.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today