A nurse is attending to a patient with a bowel obstruction who has been prescribed a nasogastric tube. What steps should the nurse take during the insertion of the nasogastric tube?
Remove the tube if the patient gags during insertion.
Advise the patient to tuck his chin to his chest and swallow.
Position the patient in a supine position.
Measure the tube for insertion from the nose tip to the navel.
The Correct Answer is B
Choice A rationale:
Removing the tube immediately upon patient gagging is not the most appropriate first step. Gagging is a common reflex during nasogastric tube insertion and can often be managed without removing the tube.
Premature removal could lead to unnecessary discomfort for the patient and potential delays in treatment.
The nurse should attempt to reposition the tube or have the patient sip water to facilitate passage before considering removal.
Choice B rationale:
Tucking the chin to the chest and swallowing are essential maneuvers that help guide the tube into the esophagus and reduce the risk of misplacement into the trachea.
These actions close off the airway and open the esophagus, creating a smoother path for the tube.
The nurse should instruct the patient to perform these actions during insertion to promote successful placement.
Choice C rationale:
While a supine position is often used for nasogastric tube insertion, it is not the most crucial factor for success.
Studies have shown that a high-Fowler's position (sitting upright with head elevated) may be equally effective and potentially more comfortable for patients.
The nurse should consider patient comfort and potential contraindications (such as respiratory distress) when choosing the most appropriate position.
Choice D rationale:
Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement. The correct measurement is from the nose tip to the earlobe to the xiphoid process (NEX).
This landmark-based method provides a more reliable estimation of the distance to the stomach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Intractable pain is pain that is persistent and does not respond to usual pain management methods. While angina can be intractable in some cases, it does not typically manifest as pain in the arm and jaw. Moreover, the patient in this scenario has not yet undergone pain management efforts, so it's premature to classify the pain as intractable.
Choice B rationale:
Phantom pain is pain that is felt in a part of the body that has been amputated or is no longer there. The patient in this scenario has not experienced any amputations, so phantom pain is not a valid explanation for the arm and jaw pain.
Choice C rationale:
Referred pain is pain that is felt in a part of the body that is different from the source of the pain. This is the most likely explanation for the arm and jaw pain in this patient. The heart and the arm and jaw share nerve pathways, so pain signals from the heart can be misinterpreted by the brain as coming from these other areas. This is a common phenomenon in patients with angina.
Choice D rationale:
Cramping pain is a type of pain that is often described as a muscle tightening or squeezing sensation. It is not typically associated with angina. While angina can sometimes cause chest tightness, it's not characterized by cramping in the arm and jaw.
Correct Answer is D
Explanation
Rationale for Choice A:
Diuretics promote fluid loss, increasing the risk of fluid volume deficit.
Heart failure can lead to fluid retention, but diuretic therapy is often used to manage this excess fluid.
However, in this case, the patient is receiving diuretic therapy, which suggests that their fluid status is being actively managed.
Therefore, while this patient is at risk for fluid volume deficit, they are not the most likely candidate among the options presented.
Rationale for Choice B:
Gastroenteritis can lead to fluid loss through vomiting and diarrhea.
However, this patient is receiving oral fluids, which helps to replenish lost fluids and electrolytes.
As long as the patient is able to tolerate oral fluids and is not experiencing excessive fluid losses, they are not at significant risk for fluid volume deficit.
Rationale for Choice C:
End-stage kidney disease can impair the kidneys' ability to regulate fluid balance.
However, dialysis is a treatment that helps to remove excess fluid and waste products from the body.
Therefore, while this patient is at risk for fluid volume imbalances, they are receiving treatment to manage this risk.
Rationale for Choice D:
NPO status means that the patient has been instructed to have nothing by mouth. This means that the patient has not been able to consume any fluids since midnight.
Even in the absence of excessive fluid losses, this prolonged period of fluid restriction can lead to dehydration and fluid volume deficit.
Therefore, this patient is the most likely to be experiencing fluid volume deficit among the options presented.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today