A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?
Wear sterile gloves to insert the NG tube.
Ask the client to cough while inserting the NG tube.
Place the client into a left lateral position before inserting the NG tube.
Determine the length of the NG tube to be inserted prior to the procedure.
The Correct Answer is D
Choice A reason: Sterile gloves are not required for inserting an NG tube; clean gloves are sufficient as the nasal
cavity is not a sterile environment.
Choice B reason: The client should not be asked to cough while inserting the NG tube as this could disrupt the placement process. Instead, the client may be asked to swallow to facilitate the passage of the tube.
Choice C reason: Placing the client into a left lateral position is not the standard position for NG tube insertion. The
client should be in an upright or semi-Fowler's position to aid in the insertion process.
Choice D reason: Determining the length of the NG tube to be inserted is a crucial step to ensure that the tube
reaches the stomach without coiling in the esophagus or extending into the small intestine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Muscle weakness is a common symptom of hypokalemia, as potassium is crucial for muscle function and nerve signals that stimulate muscle contractions.
Choice B reason: Cerebral edema is not a typical manifestation of hypokalemia. It is more commonly associated with other conditions such as brain injury or disease.
Choice C reason: Hypertension is generally not a direct result of hypokalemia. In fact, low potassium levels can sometimes lead to lower blood pressure.
Choice D reason: Hyperactive bowel sounds are not specifically associated with hypokalemia. Diarrhea can cause fluid loss leading to hypokalemia, but the condition itself does not cause hyperactive bowel sounds.
Correct Answer is B
Explanation
Choice A reason: Dark-colored urine can be a sign of dehydration or the presence of certain substances in the urine, such as blood or bile, but it is not typically associated with urinary retention.
Choice B reason: Leakage of urine, or overflow incontinence, can occur in urinary retention when the bladder is overfilled and the pressure within the bladder exceeds urethral resistance. This can lead to involuntary release of urine.
Choice C reason: Blood in the urine, or hematuria, can indicate various conditions, including infections, stones, or tumors, but it is not a common finding specifically associated with urinary retention.
Choice D reason: Cloudy urine may suggest the presence of phosphates (a normal occurrence in alkaline urine), infection, or the presence of pus (pyuria). While it could be associated with a urinary tract infection that might lead to urinary retention, cloudy urine itself is not a direct indicator of urinary retention.
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