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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Verifying the bilirubin level of the tube contents is not a reliable method for confirming tube placement and may not provide accurate information.
B. Auscultating for air insufflation can help detect tube placement in the respiratory tract but may not reliably confirm placement in the gastrointestinal tract.
C. Requesting a chest x-ray is the most reliable method for confirming the placement of a feeding tube, as it allows visualization of the tube's position relative to anatomical landmarks.
D. Checking the pH level of gastric contents can help differentiate between gastric and respiratory placement but may not provide definitive confirmation of tube placement.
Correct Answer is B
Explanation
A. Assign different nurses to provide care for clients each day- Continuity of care is important for building rapport and trust between clients and their healthcare providers.
B. Restrict the number of visitors for clients- Limiting visitors can help reduce noise and stress for clients, promoting rest and recovery.
C. Offer the clients many choices regarding care- While autonomy is important, offering too many choices can be overwhelming for clients, especially in a stressful environment like an acute care unit.
D. Turn on loud music in client care areas- Loud music can increase stress and discomfort for clients, especially those who are trying to rest or recover.
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