The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

Use firm pressure to pass the tube through the glottis.

Have the client tilt head backward to open the passage.

Give the client a few sips of water to drink.

Remove the tube and attempt reinsertion.

Answer and Explanation

The Correct Answer is C

A. Using firm pressure to pass the tube through the glottis can cause discomfort and potentially damage the client's airway. It is important to proceed with caution and avoid causing harm.
B. Tilting the head backward can actually make the insertion more difficult and increase the risk of gagging or aspiration. Proper head positioning typically involves slight flexion.
C. Giving the client sips of water is not recommended during NGT insertion as it can exacerbate gagging and increase the risk of aspiration.
D. Removing the tube and attempting reinsertion is the appropriate action if the client begins to gag. It allows the nurse to reposition the tube and attempt insertion more gently, ensuring the tube is correctly placed without causing undue discomfort or harm.

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Correct Answer is C

Explanation

A. Adjusting the hand grips is necessary to ensure that the client can bear weight comfortably through the arms without placing stress on the wrists or shoulders, so avoiding this adjustment is incorrect.
B. Holding the crutch 6 inches to the side is a common guideline, but it is not as crucial as ensuring the correct fit of the crutches to avoid axillary nerve damage and ensure proper posture.
C. The crutch should fit 2 finger widths below the axilla to prevent pressure on the brachial plexus nerves, which can lead to nerve damage. This demonstrates an understanding of proper crutch fit and use.
D. Walking with the arms fully extended is incorrect; the arms should be slightly bent at the elbows to allow for proper weight distribution and movement.

A. Notify the information services department of the situation. B. Print electronic medical record (EMR) from the backup server. C. Identify information as a late entry in the record. D. Wait for notification that the system has been rebooted.

Correct Answer is A

Explanation

A. The first priority is to notify the information services department to address the technical issue with the computer system. This ensures that the problem is being handled and allows the nurse to focus on immediate patient care needs.
B. Printing the EMR from the backup server is not possible until the issue with the computer system is resolved. Immediate reporting to IT is necessary to address the technical problem first.
C. Identifying information as a late entry is premature and not the immediate priority. Ensuring the functionality of the electronic system is crucial before making manual records.
D. Waiting for the system to reboot does not address the immediate need for technical support and may delay patient care.

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The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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