A client is admitted for blunt force chest trauma following a motor vehicle collision. A nasogastric (NG) tube was inserted in the emergency department and chest x-ray results indicate that the tip of the NG tube is in the left chest. Which priority action(s) should the nurse implement? Select all that apply.

Insert 30 mL air bolus while auscultating over abdomen.

Remove the NG tube.

Clamp the NG tube.

Auscultate chest and abdomen following removal of NG tube.

Connect the NG tube to low wall suction.

Answer and Explanation

Correct Answer : B,C,D

Rationale:

A. Insert 30 mL air bolus while auscultating over abdomen: Introducing air into a misplaced NG tube in the chest cavity may worsen injury or cause a pneumothorax or tension pneumothorax, especially if the tube has entered the pleural space or lung.

B. Remove the NG tube: Chest x-ray confirms malposition in the chest cavity, likely the pleural space or lung. The tube must be removed immediately to prevent further trauma or air/fluid accumulation.

C. Clamp the NG tube: Clamping prevents the entry or exit of air and fluids, minimizing risk of complications like aspiration or worsening pneumothorax while awaiting removal or re-evaluation.

D. Auscultate chest and abdomen following removal of NG tube: Assessing for abnormal breath or bowel sounds post-removal helps detect potential complications such as pneumothorax, hemothorax, or abdominal injury.

E. Connect the NG tube to low wall suction: Connecting a malpositioned NG tube to suction could draw air or fluids from the pleural space or lung, worsening the trauma or leading to complications such as lung collapse.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Apply bilateral eye patches while sleeping: Routine patching is not typically required after photocoagulation. This intervention may impair safety and independence unnecessarily, especially if only one eye was treated.

B. Arrange food on the plate in clockwise order: This technique supports clients with total blindness, but photocoagulation for macular degeneration usually preserves peripheral vision. Clock-face plate arrangement may not be necessary for partial vision loss.

C. Verbally identify self when entering the room: Clients with macular degeneration often lose central vision but retain peripheral vision. Verbal identification helps orient and reassure the client, supporting emotional comfort and safety in the postoperative period.

D. Use a white board to communicate ideas: White boards require intact central vision for reading. Clients with macular degeneration may struggle to see text, so verbal communication is generally more effective and appropriate.

A. Encourage wearing a medical alert identification bracelet. B. Explain the importance of counting carbohydrate intake. C. Provide printed materials about the treatment of diabetes. D. Teach how to recognize and treat hypoglycemia.

Correct Answer is D

Explanation

Rationale:
A. Encourage wearing a medical alert identification bracelet: While important for safety, especially in emergencies, it does not directly affect daily self-management or immediate health risks like hypoglycemia.

B. Explain the importance of counting carbohydrate intake: Carbohydrate counting is vital for glucose management but becomes more effective once the client understands how to handle acute complications like hypoglycemia.

C. Provide printed materials about the treatment of diabetes: Educational materials support learning, but the nurse must prioritize hands-on, actionable education—especially about emergencies like hypoglycemia.

D. Teach how to recognize and treat hypoglycemia: Hypoglycemia can occur quickly and lead to seizures, unconsciousness, or death if untreated. Teaching recognition and response is the most urgent priority for client safety.

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Naxlex Comprehensive Predictor Exams

An older adult client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the postprocedure care in the outpatient surgical unit?

Correct Answer is C

Explanation

When providing education for a client newly diagnosed with type 1diabetes, which information is most important for the nurse to provide the client?

Correct Answer is D

Explanation

Which nursing intervention is indicated for the second stage of labor?

Exhibits The nurse reviews the clinical findings. For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing interventions should the nurse include in the client's plan of care? Select all that apply.

The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available?