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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. The client is sedentary throughout most of the day: While physical inactivity can lead to health issues such as muscle weakness and cardiovascular problems, it is not immediately life-threatening and can be addressed through lifestyle interventions.

B. The client verbalizes regret about never marrying: This reflects emotional distress or social isolation, which is important, but it does not pose an urgent physical health risk requiring immediate attention.

C. The client has no living family: Although lacking family support can affect long-term care planning and emotional well-being, it is not the most immediate threat to the client’s health in this context.

D. The client has poorly fitting dentures: This is the priority because it directly affects the client’s ability to eat, leading to potential malnutrition, weight loss, and decline in overall health—issues particularly dangerous for older adults.

A. Dietary intake B. Pain level C. Blood pressure D. Informed consent E. Oxygen saturation F. Allergies

Correct Answer is ["A","B","F"]

Explanation

A. Dietary intake: The client ate toast at 0600 and experienced vomiting. Since general anesthesia is typically used for an appendectomy, recent food intake increases the risk of aspiration and should be reported immediately to the surgical team.

B. Pain level: The client reports increasing pain (now 8/10) with rebound tenderness. This may indicate worsening inflammation or risk of rupture, which requires reassessment and potentially expedited surgical intervention.

C. Blood pressure: The blood pressure of 124/80 mm Hg is within normal limits and does not require follow-up before surgery. It reflects stable hemodynamics.

D. Informed consent: The provider has already obtained informed consent and placed it in the medical record. No further follow-up is needed unless the client withdraws consent or shows signs of confusion.

E. Oxygen saturation: The client's oxygen saturation is 96% on room air, which is acceptable. There are no indications of respiratory compromise that require further intervention preoperatively.

F. Allergies: The client reports allergies to shellfish, latex, and penicillin. These pose serious risks during surgery (e.g., anaphylaxis to latex gloves or antibiotics) and must be addressed in the preoperative checklist to ensure appropriate substitutes are used.

View Question and Answer

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

A nurse is preparing to insert a client's NG tube for enteral feedings. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who is scheduled for an appendectomy. Exhibits The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

Correct Answer is ["A","B","F"]

Explanation

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard?

A nurse is preparing to assist a client out of bed to a wheelchair following left knee surgery. The nurse should identify that which of the following images indicates the correct placement of the wheelchair?

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?

A nurse is applying cold therapy to a client's face following oral surgery. The nurse should identify that which of the following is a therapeutic effect of cold therapy?

A nurse is caring for a client who has chronic constipation. Which of the following actions should the nurse recommend to the client?

A nurse is observing an assistive personnel (AP) who is performing hand hygiene. The nurse should recognize that the AP is using proper technique when he does which of the following?

A nurse is assisting in the care of a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.

A nurse is caring for a client who has expressive aphasia. Which of the following techniques should the nurse use to meet the communication needs of this client?