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 into the box on the right, placing them in the order of performance. Use all the steps.)
Apply clean gloves.
Ask the client to take a deep breath.
Instill 50 mL of air into the tube.
Pinch and withdraw the tube.
Disconnect the tube from the suction device.
The Correct Answer is E,C,B,D,A
E. Disconnect the tube from the suction device:
Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.
C. Instill 50 mL of air into the tube:
Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.
B. Ask the client to take a deep breath:
Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.
D. Pinch and withdraw the tube:
Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.
A. Apply clean gloves:
Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.
Choice B Reason:
Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.
Choice C Reason:
Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.
In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:
Choice D Reason:
Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.
Correct Answer is D
Explanation
Choice A Reason:
Chicken is incorrect. Chicken is a type of poultry and is a meat product. Lacto-vegetarians do not consume meat, including poultry, as part of their dietary choices.
Choice B Reason:
Clam chowder is incorrect. Clam chowder is a soup typically made with clams and often contains ingredients like broth or cream, which may not align with a lacto-vegetarian diet. It includes seafood, which is excluded in lacto-vegetarian dietary practices.
Choice C Reason:
Tuna fish is incorrect. Tuna fish is a type of seafood and is not consumed in lacto-vegetarian diets. Lacto-vegetarians exclude all types of fish and seafood from their diet and primarily consume dairy products along with plant-based foods.
Given that the client follows a lacto-vegetarian diet, the most appropriate food choice from the options provided would be:
Choice D is Reason:
Cheese is correct. A lacto-vegetarian diet includes dairy products but excludes meat and seafood. Cheese, being a dairy product, aligns with the lacto-vegetarian dietary pattern as it is derived from milk and fits within the dietary preferences of this individual.
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