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 A

Explanation

A) Play music in the client's room. - Music therapy can be a beneficial nonpharmacological intervention for managing pain and promoting relaxation.
B) Keep the client's room well lit. - Bright lighting may exacerbate pain for some clients; dim lighting or allowing the client to control the lighting can be more helpful.
C) Ensure that the client's room is kept at a cool temperature. - Temperature preferences can vary among individuals; the nurse should adjust the room temperature according to the client's comfort.

D) Encourage the client to abstain from distracting activities. - Engaging in distracting activities can help divert the client's attention from pain, so encouraging them may be appropriate.

A. Place the specimen in a clean specimen cup. B. Clamp the catheter tubing below the needleless port. C. Clamp the catheter tubing for 60 min. D. Remove 45 mL of urine from the catheter with a syringe.

Correct Answer is B

Explanation

A) Place the specimen in a clean specimen cup. - Urine collected from an indwelling urinary catheter should be obtained using a sterile technique, not placed directly into a clean specimen cup.
B) Clamping the catheter tubing for 10–30 minutes before collecting the sample allows fresh urine to accumulate in the tubing, ensuring a more accurate culture result. The urine should be collected from the designated port using aseptic technique, not from the catheter bag, as stagnant urine may contain contaminants.

C) Clamp the catheter tubing for 60 min. - Clamping the tubing for an extended period can cause urinary retention and discomfort for the client. It is not appropriate for collecting a urine specimen.
D) Only 3–5 mL of urine is needed for a culture.The nurse should collect the appropriate small amount to avoid unnecessary removal of urine.

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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 providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take

Correct Answer is A

Explanation

A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

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A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

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.)

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