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 A
Explanation
Choice A Reason:
This is the correct action. A filter needle should be used when drawing medication from an ampule to prevent glass particles from being aspirated into the syringe and subsequently administered to the patient.
Choice B Reason:
Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.
Choice C Reason:
This is not necessary. Once the ampule is opened, it should be handled with care to avoid contamination, but cleansing the tip with an alcohol swab is not a standard practice since it does not effectively remove glass particles.
Choice D Reason:
This is incorrect. Ampules are not pressurized containers, and injecting air into an ampule is unnecessary and could cause the medication to spill out or create bubbles that interfere with accurate dosing.
Correct Answer is C
Explanation
Training the bladder by voiding every 5 hr. is incorrect. For individuals experiencing urinary incontinence, scheduled voiding at regular intervals might be a part of the management plan. However, the specific interval of every 5 hours might not suit everyone, as it depends on individual bladder capacity and function. Scheduled voiding should be tailored to the individual's needs and not solely based on a fixed time frame.
Choice B Reason:
Applying adult diapers at bedtime is incorrect. While using protective garments like adult diapers may manage urinary incontinence during sleep, it doesn't address the underlying issue or provide a solution to improve the condition.
Choice C Reason:
Performing pelvic-muscle exercises is correct. Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the bladder and control urine flow. This can potentially improve urinary incontinence by enhancing bladder control.
Choice D Reason:
Drinking citrus juice with meals is incorrect. Citrus juices can irritate the bladder and potentially exacerbate urinary incontinence for some individuals. Advising the consumption of citrus juice might not be beneficial and could worsen symptoms in certain cases.
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