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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale:

A. Restrict alcohol intake to 350 mL (12 oz) of wine per day: This recommendation exceeds the safe alcohol limit for individuals at risk for hypertension. For women, the limit is typically one drink per day, and for men, up to two.

B. Limit caloric intake to 2,500 calories per day: 2,500 calories may still be excessive for many individuals, especially those with sedentary lifestyles. Hypertension risk is more effectively reduced through balanced nutrition and physical activity, not just calorie limits.

C. Walk for 30 min 5 days per week: Regular aerobic exercise like walking improves cardiovascular health and is strongly recommended to prevent and manage hypertension. This frequency and duration align with guidelines to lower blood pressure and support overall wellness.

D. Increase dietary intake of canned vegetables: Canned vegetables often contain high sodium levels, which can contribute to elevated blood pressure. Clients at risk for hypertension should be encouraged to choose fresh or low-sodium alternatives to help control sodium intake.

A. Maintain the client in high-Fowler's position. B. Increase the client's intake of oral fluids. C. Instruct the client to cough every 4 hr. D. Encourage the client to ambulate to loosen secretions.

Correct Answer is A

Explanation

Rationale:

A. Maintain the client in high-Fowler's position: Placing the client in high-Fowler's position improves lung expansion and decreases pulmonary congestion by lowering venous return to the heart. This is a priority intervention for managing dyspnea and crackles in heart failure.

B. Increase the client's intake of oral fluids: Increasing fluid intake may worsen fluid overload in clients with heart failure. These clients typically require fluid restrictions to prevent exacerbation of symptoms like pulmonary edema.

C. Instruct the client to cough every 4 hr: While coughing can help clear secretions, the symptoms in this scenario are related to fluid overload, not mucus accumulation. Coughing alone will not relieve the pulmonary congestion seen in heart failure.

D. Encourage the client to ambulate to loosen secretions: Ambulation has benefits but is not the first action when the client is short of breath and showing signs of pulmonary congestion. Activity should be limited until respiratory status stabilizes.

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A nurse is preparing to insert a nasogastric tube in a client. Which of the following actions should the nurse take?

Nursing Test Bank

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