A nurse is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?
Mark the length to be inserted on the tube with tape.
Instruct the client to hyperextend her neck.
Place a water-based lubricant on the tip of the tube.
Compare the patency of the client's nares.
The Correct Answer is D
A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.
B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.
C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.
D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Leave the needle in place for 10 seconds after the injection: Leaving the needle in place for approximately 10 seconds after administering a subcutaneous injection helps ensure full delivery of the medication and reduces the chance of medication leakage at the injection site.
B. Use a 5-inch needle for the injection: A 5-inch needle is excessively long for subcutaneous injections and would likely penetrate muscle tissue, increasing the risk of injury or incorrect medication administration. Subcutaneous injections typically require a needle length between ⅜ and ⅝ inch.
C. Inject the medication using the Z-track technique: The Z-track technique is used for intramuscular injections to minimize medication leakage and reduce irritation. It is not appropriate for subcutaneous injections, which are administered into the fatty layer beneath the skin, not deep muscle tissue.
D. Insert the syringe at a 15° angle during injection: A 15° angle is used for intradermal injections. Subcutaneous injections should be administered at a 45° to 90° angle depending on the client’s body mass to ensure the medication is delivered into the subcutaneous tissue, not the dermis or muscle.
Correct Answer is B
Explanation
A. Testicular examination: Testicular cancer screening is typically encouraged from adolescence to around age 35, as it is more common in younger men. Routine testicular exams are not specifically recommended starting at age 50.
B. Colonoscopy: Colorectal cancer screening, such as colonoscopy, should begin at age 45 or 50 for individuals at average risk. It is a key preventive measure for detecting colorectal cancer in its early stages.
C. Clinical breast examination: Clinical breast exams may be done earlier, typically starting in the 20s or 30s, depending on risk factors. They are not newly initiated at age 50.
D. Fasting blood glucose: Screening for diabetes may begin as early as age 35 in adults with risk factors. It is important but not specifically recommended as a new screening starting at age 50.
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