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. Raising the head off the pillow is not relevant to easing the passage of the catheter through the urinary meatus.
B. Bearing down can help relax the pelvic floor muscles, making it easier to insert the catheter through the urinary meatus.
C. Holding the breath is not typically instructed during catheter insertion and may not aid in the ease of the procedure.
D. Performing Kegel exercises involves contracting pelvic floor muscles, which is not the desired action when inserting a urinary catheter.

A. Right task B. Right communication C. Right person D. Right circumstance

Correct Answer is A

Explanation

A. The right task involves ensuring that the delegated task is appropriate for delegation. In this case, obtaining an oral temperature should have been the correct task; however, the AP
performed the axillary temperature, indicating a deviation from the right task.
B. Right communication involves clear and effective communication between the nurse and the assistive personnel but is not directly related to the task performed.
C. Right person involves ensuring that the task is delegated to a competent and qualified

individual. The issue in this scenario is with the task itself, not the competency of the individual.

D. Right circumstance involves ensuring that the conditions are appropriate for delegation. While the circumstance is important, the primary concern in this case is the mismatch between the task and the method of temperature measurement.

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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

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to help ease the passage of the catheter through the urinary meatus?

Correct Answer is B

Explanation

A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

Correct Answer is A

Explanation

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