A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

"Raise the index finger if gagging occurs during insertion."

"Bear down during insertion."

Say "stop" if a burning sensation is felt inside the nose."

Inhale forcefully during insertion."

Answer and Explanation

The Correct Answer is C

A.   Raising the index finger is not a typical response for managing gagging during NG tube insertion.

B.   Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C.   Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D.   Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.

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Correct Answer is B

Explanation

A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping

A. Test for the presence of the client's gag reflex. B. Lubricate the lips with petroleum jelly. C. Place the client in the supine position. D. Use a firm toothbrush for tooth and gum care.

Correct Answer is B

Explanation

A. Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B. Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C. Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D. Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

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A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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