A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)

Pinch and withdraw the tube.

Disconnect the tube from the suction device.

Instill 50 mL of air into the tube.

Ask the client to take a deep breath.

Apply clean gloves.

Answer and Explanation

The Correct Answer is E,B,C,D,A

First, the nurse should apply clean gloves (E) to maintain sterility and safety. Next, the nurse should disconnect the tube from the suction device (B), ensuring that the device is no longer actively working on the tube.

Before removing the tube, it is important to instill air into it (C); this helps clear any residual contents and minimizes the risk of aspiration. The nurse should then ask the client to take a deep breath (D), which helps close the epiglottis to prevent aspiration during the removal of the tube. Finally, the nurse can pinch and withdraw the tube (A), completing the process in a swift, steady motion to ensure comfort and safety for the client.

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Correct Answer is B

Explanation

A) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

B) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

C) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

D) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

A. Obtain verbal consent from the client. B. Witness the client's signature on a consent form. C. Check the medical record for the client's signature on a previous consent form. D. Have another nurse co-sign the client's consent

Correct Answer is B

Explanation

A) Obtain verbal consent from the client. - While obtaining verbal consent is important, for invasive procedures like catheter insertion, it's essential to have written, witnessed consent to ensure proper documentation and confirmation that the client is fully informed and agrees to the procedure.
B) Witness the client's signature on a consent form. - Express consent for medical procedures typically involves the client signing a consent form after being adequately informed about the procedure, its potential risks, benefits, and alternatives. Witnessing the client's signature on a consent form ensures that the client has provided informed consent for the specific procedure.
C) Check the medical record for the client's signature on a previous consent form. - Consent for procedures should ideally be obtained for each specific instance, especially for invasive procedures.
D) Have another nurse co-sign the client's consent. - Co-signing consent is not necessary for minor procedures like urinary catheter insertion; verbal consent from the client is sufficient.

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A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?

Correct Answer is B

Explanation

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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