A nurse is caring for a patient who needs a nasogastric (NG) tube for stomach decompression. Which of the following steps should the nurse take when inserting the NG tube?

Position the patient with the head of the bed elevated to 30 degrees prior to insertion of the NG tube.

Remove the NG tube if the patient begins to gag or choke.

Apply suction to the NG tube prior to insertion.

Encourage the patient to take sips of water to facilitate the insertion of the NG tube into the esophagus.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.

Choice B rationale

If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.

Choice C rationale

Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.

Choice D rationale

Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.

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Correct Answer is C

Explanation

Choice A rationale

Tuberculosis is a serious infectious disease that affects the lungs. However, it does not typically cause lung hyperinflation.

Choice B rationale

Bronchitis is an inflammation of the bronchial tubes. While it can cause symptoms similar to those described, it does not typically cause lung hyperinflation or localized pneumonia in the left upper lobe.

Choice C rationale

Pneumonia is an infection that inflames the air sacs in one or both lungs. The client’s symptoms of a productive cough with thick yellow sputum, crackles in the left upper lobe, and decreased breath sounds at bases bilaterally are consistent with pneumonia. The chest x-ray showing left upper lobe pneumonia confirms this diagnosis.

Choice D rationale

Asthma is a condition in which a person’s airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe. While asthma can cause lung hyperinflation, it does not typically cause localized pneumonia in the left upper lobe.

A. Place a pillow under the patient’s knees. B. Position a trochanter roll under each of the patient’s hips. C. Advise the patient to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the patient’s feet.

Correct Answer is D

Explanation

Choice A rationale

Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.

Choice B rationale

Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.

Choice C rationale

Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.

Choice D rationale

Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.

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A nurse is caring for a patient who needs a nasogastric (NG) tube for stomach decompression. Which of the following steps should the nurse take when inserting the NG tube?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client’s chest x-ray shows lung hyperinflation and left upper lobe pneumonia. What is the most likely diagnosis?

Correct Answer is C

Explanation

A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?

Correct Answer is D

Explanation

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