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 D

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","D","E"]

Explanation

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

A. Warn the colleague that their actions are unprofessional. B. Discuss the action at the next staff meeting. C. Communicate the observation to the charge nurse. D. File a detailed incident report with the specific facility.

Correct Answer is C

Explanation

A. While it is important to address unprofessional behavior, directly warning the colleague may not be sufficient to address the breach of security protocols effectively.
B. Discussing the action at a staff meeting may not address the immediate issue and could lead to general discussions rather than specific corrective actions.
C. Communicating the observation to the charge nurse is appropriate because it ensures that the issue is reported to a person who can take immediate action to address the breach of EHR security and prevent further unauthorized access.
D. Filing a detailed incident report may be necessary, but first, informing the charge nurse is crucial for immediate action and to address the issue promptly. The charge nurse can then guide the next steps, including filing a report if necessary.

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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

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Explanation

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Correct Answer is C

Explanation

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