A nurse is preparing to insert a nasogastric tube in a client. Which of the following actions should the nurse take?
Encourage client to swallow while advancing tube
Measure the length of the tube from client's nose to shoulder
Place client in semi-Fowler's position in bed
Advance tube during client's inspiration
The Correct Answer is A
Rationale:
A. Encourage client to swallow while advancing tube: Swallowing facilitates the passage of the nasogastric tube through the oropharynx and esophagus by closing the epiglottis and reducing the risk of the tube entering the trachea. This action helps guide the tube smoothly into the stomach.
B. Measure the length of the tube from client's nose to shoulder: Proper measurement involves extending the tube from the nose to the earlobe and then down to the xiphoid process, not just to the shoulder.
C. Place client in semi-Fowler's position in bed: The client should be placed in a high-Fowler’s position, not semi-Fowler’s, to promote comfort and reduce the risk of aspiration. This upright position also allows for easier passage of the tube through the upper GI tract.
D. Advance tube during client's inspiration: Advancing the tube during inspiration increases the risk of the tube entering the airway rather than the esophagus. The tube should be advanced when the client is swallowing, which helps direct it into the digestive rather than respiratory tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Calculation:
Total volume to be infused = 500 mL.
- Convert the infusion time from hours to minutes.
Infusion time = 4 hr × 60 min/hr
= 240 min.
Drop factor = 15 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)
= (500 mL × 15 gtt/mL) / 240 min
= 7500 gtt / 240 min
= 31.25 gtt/min.
Rounded to the nearest whole number:
= 31 gtt/min.
Correct Answer is B
Explanation
Rationale:
A. Eat foods high in vitamin B: Although B-vitamin deficiencies can contribute to stomatitis, eating foods high in vitamin B may not immediately relieve symptoms. Nutritional support is important long-term, but bland food recommendations provide immediate comfort.
B. Consume soft, bland foods: Soft, bland foods reduce mechanical and chemical irritation to the oral mucosa, promoting healing and reducing discomfort. These are ideal dietary choices for clients with stomatitis.
C. Rinse the mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can worsen irritation and dryness of the oral mucosa, aggravating stomatitis symptoms. Alcohol-free rinses or saline solutions are better alternatives.
D. Use lemon glycerin swabs: Lemon glycerin swabs can cause further drying and irritation of the mucosa. They are not recommended for clients with stomatitis, as they may intensify pain and inflammation.
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