A client with a nasogastric tube has an order for the tube to be removed.
As the nurse removes the tube, the client should be asked to:
Breathe in and out normally.
Take a deep breath and cough.
Hold her breath.
Bear down like having a bowel movement.
The Correct Answer is C
Choice A rationale
Breathing in and out normally does not protect the airway during nasogastric tube removal. The risk of aspiration is present as the tube is withdrawn, and normal breathing does not actively close off the trachea.
Choice B rationale
Taking a deep breath and coughing can help to clear the airway after the tube is removed but does not directly aid in preventing aspiration during the removal process itself. Coughing expels material from the lungs and throat.
Choice C rationale
Holding her breath during nasogastric tube removal helps to close the epiglottis, which covers the trachea. This action minimizes the risk of aspiration of any residual secretions or reflux that might occur as the tube is being withdrawn.
Choice D rationale
Bearing down, or performing the Valsalva maneuver, increases intra-abdominal pressure and is typically used to stimulate a bowel movement. It is not relevant to protecting the airway during nasogastric tube removal and could potentially increase the risk of reflux.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Chicken is poultry, and a lacto-ovo vegetarian diet excludes all meat, poultry, and fish. Grilled eggplant and cheese are acceptable as they are vegetables and dairy products, respectively. However, the presence of chicken makes this choice incorrect for a lacto-ovo vegetarian.
Choice B rationale
Boiled eggs are permitted in a lacto-ovo vegetarian diet as it includes eggs and dairy. Chocolate milk is also allowed as it is a dairy product. This choice aligns with the definition of a lacto-ovo vegetarian diet, which includes dairy and eggs but excludes meat, poultry, and fish.
Choice C rationale
Oysters are shellfish, and turkey is poultry, both of which are excluded from a lacto-ovo vegetarian diet. Yogurt is a dairy product and is acceptable. The inclusion of oysters and turkey makes this choice incorrect.
Choice D rationale
Fish is not allowed in a lacto-ovo vegetarian diet. Milk is a dairy product and is acceptable. Poached eggs are also permitted. The presence of fish makes this choice incorrect.
Correct Answer is C
Explanation
Choice A rationale
A BMI of 30 or higher is classified as obese. Class 1 obesity is defined as a BMI between 30 and 34.9. Chelsea's BMI of 17 is significantly lower than this range.
Choice B rationale
Class 2 obesity is defined as a BMI between 35 and 39.9. Chelsea's BMI of 17 is considerably below this classification.
Choice C rationale
A BMI below 18.5 is classified as underweight. Chelsea's BMI of 17 falls within this range, indicating that her weight is lower than what is considered healthy for her height.
Choice D rationale
A normal weight range is typically defined as a BMI between 18.5 and 24.9. Chelsea's BMI of 17 is below this healthy range.
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