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 B

Explanation

A. The hospital pharmacist can provide valuable information about medication dosages and potential discrepancies, but the primary source for clarification about the prescribed treatment plan is the healthcare provider who issued the prescription.
B. The healthcare provider should be contacted first to clarify the dosage discrepancy. The provider can confirm whether the dosage is correct or if there was an error in the prescription. This ensures that any potential issues are addressed by the person responsible for the treatment plan.
C. A medication reference guide is useful for checking normal dosages, but it does not clarify if a specific prescription is appropriate for the client’s condition. The provider’s confirmation is necessary for resolving discrepancies.
D. The nursing unit charge nurse may be consulted for additional guidance but is not the primary resource for verifying or resolving prescription dosages.

A. Elevate the area and apply light pressure over the site. B. Apply a cold pack to the area for twenty minutes. C. Document the site where the medication was given. D. Notify the healthcare provider of the allergic response.

Correct Answer is C

Explanation

A. Elevating the area and applying light pressure is not appropriate for a small raised area from an intradermal injection, which is usually a normal reaction and not an indication for elevation or pressure.
B. Applying a cold pack is unnecessary and may not be appropriate unless there is significant discomfort or an allergic reaction, which is not suggested by the description of a small, raised area.
C. Documenting the site where the medication was given is important for record-keeping and monitoring the reaction to the intradermal test. This helps in assessing normal reactions versus abnormal ones later.
D. Notifying the healthcare provider of an allergic response should be done if the reaction is severe or unexpected, but a small, round raised area is typically a normal response to an intradermal injection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer is C

Explanation

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