A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first?
Verify provider order to discontinue the tube.
Observe the amount and color of drainage.
Perform hand hygiene and don gloves.
Disconnect the tube from the wall suction.
The Correct Answer is A
A. Verify provider order to discontinue the tube:
The first action in the nursing process is to verify the provider’s order before removing any medical device. It ensures the action is legally and clinically appropriate.
B. Observe the amount and color of drainage:
Important to evaluate after the order is confirmed, but not the first step.
C. Perform hand hygiene and don gloves:
Necessary for infection control, but only after verifying the order.
D. Disconnect the tube from the wall suction:
This is part of the procedure itself, not the initial preparatory step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Constipation:
Constipation is not a typical sign of hyponatremia. It’s more common with dehydration or decreased GI motility.
B. Headache:
A sodium level of 128 mEq/L indicates hyponatremia, which can cause cerebral edema, leading to symptoms like headache, confusion, and seizures.
C. Hyporeflexia:
Hyponatremia may cause hyperreflexia or muscle cramps, not usually hyporeflexia.
D. Increased appetite:
Appetite is not typically affected by hyponatremia. Nausea and vomiting are more likely.
Correct Answer is A
Explanation
A. "I will check your medication prescription again.":
This is the most appropriate and client-centered response. It acknowledges the client’s concern and prioritizes safety.
B. "Let me explain the purpose of the medication.":
Education is important, but confirming the medication comes first to ensure accuracy before administering.
C. "Sometimes the same pill comes in a different color.":
This may be true but can come off as dismissive without verifying the medication first.
D. "This is the medication that your doctor wants you to take.":
This is dismissive of the client’s concern and bypasses necessary safety verification steps.
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