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 The risk of aspiration is present as the tube is withdrawn, and normal breathing does not actively close off the trachea.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This action minimizes the risk of aspiration of any residual secretions or reflux that might occur as the tube is being withdrawn.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
Nutrisystems is a commercial weight loss program that provides pre-packaged meals. While it may be effective for some, it is not directly sponsored by the USDA and might not align with the specific dietary recommendations promoted by the government for overall health.
Choice B rationale
MyPlate is a nutritional guide developed by the United States Department of Agriculture (USDA). It is designed to help Americans make healthier food choices by illustrating the five food groups and providing recommendations on portion sizes and a balanced diet. This is a direct resource sponsored by the USDA.
Choice C rationale
Weight Watchers (now WW) is a commercial weight loss program that utilizes a points system to guide food choices and encourages group support. While it can be a helpful resource for weight management, it is not a USDA-sponsored program.
Choice D rationale
eDiets.com is a commercial website that offers various diet plans, recipes, and fitness advice. While it may provide useful information for some individuals, it is not a resource directly sponsored or developed by the USDA.
Correct Answer is C
Explanation
Choice A rationale
Trouble chewing foods such as meats and raw vegetables is more indicative of mechanical issues with chewing or dental problems rather than dysphagia, which primarily involves difficulty with swallowing. While chewing difficulties can sometimes coexist with dysphagia, the primary characteristic of dysphagia is impaired bolus transport from the mouth to the stomach.
Choice B rationale
Awakenings with a feeling of indigestion suggest issues related to gastric motility or acid reflux, not necessarily dysphagia. Indigestion involves discomfort in the upper abdomen, often related to the digestion of food in the stomach, whereas dysphagia is focused on the process of swallowing.
Choice C rationale
A feeling of choking after swallowing is a classic symptom of dysphagia. It indicates that food or liquid is not passing smoothly from the pharynx to the esophagus and may be entering the airway. This occurs due to impaired coordination or weakness of the muscles involved in swallowing.
Choice D rationale
Frequent burping, or eructation, is typically related to the release of excess gas from the stomach, often due to swallowed air or the breakdown of food. It is not a primary indicator of dysphagia, which is a disorder of the swallowing mechanism.
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