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 The risk of aspiration is present as the tube is withdrawn, and normal breathing does not actively close off the trachea.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This action minimizes the risk of aspiration of any residual secretions or reflux that might occur as the tube is being withdrawn.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 D
Explanation
Choice A rationale
Canned pineapple, while containing some fiber, typically has a lower fiber content compared to fresh fruits, especially when the skin is removed. The canning process can also reduce the fiber content. A diet rich in fiber promotes bowel regularity, helps control blood sugar levels, and can contribute to lower cholesterol.
Choice B rationale
Mashed potatoes, particularly if made with peeled potatoes, are relatively low in dietary fiber. Most of the fiber in a potato is found in its skin. Fiber is essential for maintaining healthy bowel function, preventing constipation, and contributing to feelings of fullness, which can aid in weight management.
Choice C rationale
Celery is a source of dietary fiber, primarily in its strings. Fiber adds bulk to the stool, facilitating its passage through the digestive system and preventing constipation. Adequate fiber intake is also associated with a reduced risk of cardiovascular disease and certain types of cancer.
Choice D rationale
Pears with skin are an excellent source of dietary fiber. The skin of fruits and vegetables is often rich in fiber. Dietary fiber plays a vital role in digestive health by promoting regularity, preventing constipation, and supporting the growth of beneficial gut bacteria. It also helps regulate blood sugar and cholesterol levels.
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