A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
Verify the provider’s prescription to discontinue the tube.
Disconnect the tube from the wall suction.
Perform hand hygiene.
Provide mouth care to the client.
The Correct Answer is A
Choice A reason:
The first step in removing an NG tube is to verify the provider’s prescription to discontinue the tube. This ensures that the removal is authorized and appropriate for the client’s current condition.
Choice B reason:
Disconnecting the tube from the wall suction is an important step, but it should be done after verifying the provider’s prescription. This step prevents any suction-related complications during the removal process.
Choice C reason:
Performing hand hygiene is crucial to prevent infection, but it is not the first step. Hand hygiene should be performed after verifying the provider’s prescription and before touching the client or any equipment.
Choice D reason:
Providing mouth care to the client is important for comfort and hygiene, but it is not the first step in the process of removing an NG tube. This can be done after the tube has been safely removed.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Dependent rubor
Dependent rubor is a reddish discoloration of the skin that occurs when the leg is in a dependent position (hanging down). This condition is typically associated with arterial insufficiency rather than chronic venous insufficiency. Arterial insufficiency occurs when there is inadequate blood flow through the arteries, leading to symptoms such as pain, cramping, and changes in skin color. Dependent rubor is a sign of poor arterial circulation and is not commonly seen in venous insufficiency.
Choice B reason: Thick, deformed toenails
Thick, deformed toenails can be a sign of fungal infections or other conditions affecting the nails, but they are not specifically indicative of chronic venous insufficiency. While individuals with chronic venous insufficiency may have poor circulation that can contribute to nail problems, this symptom is not a primary or common finding associated with the condition. Instead, it is more often related to other underlying health issues.
Choice C reason: Hair loss
Hair loss on the legs can occur due to various reasons, including poor circulation. However, it is more commonly associated with arterial insufficiency rather than chronic venous insufficiency. In arterial insufficiency, the reduced blood flow can lead to hair loss, shiny skin, and other changes in the lower extremities. Chronic venous insufficiency primarily affects the veins and leads to symptoms such as swelling, varicose veins, and skin changes.
Choice D reason: Edema
Edema, or swelling, is a hallmark symptom of chronic venous insufficiency. This condition occurs when the veins in the legs are unable to effectively return blood to the heart, leading to blood pooling in the lower extremities. The increased pressure in the veins causes fluid to leak into the surrounding tissues, resulting in swelling. Edema is often more pronounced at the end of the day or after prolonged periods of standing or sitting. Managing edema is a key aspect of treating chronic venous insufficiency, and it often involves the use of compression stockings, elevation of the legs, and other measures to improve venous return.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Add Cream to Soups
Adding cream to soups is an excellent way to increase both calorie and protein intake. Cream is rich in fat and calories, which can help in weight gain and provide the necessary energy for clients undergoing chemotherapy. Additionally, it enhances the flavor and texture of soups, making them more palatable for clients who may have a reduced appetite due to treatment.
Choice B reason: Dip Meats in Eggs and Bread Crumbs Before Cooking
Dipping meats in eggs and bread crumbs before cooking adds extra calories and protein. Eggs are a good source of high-quality protein, and bread crumbs add additional calories. This method also helps to create a more appealing texture and flavor, which can be beneficial for clients experiencing taste changes due to chemotherapy.
Choice C reason: Use Milk Instead of Water in Recipes
Using milk instead of water in recipes is another effective strategy to boost calorie and protein intake. Milk contains essential nutrients, including protein, calcium, and vitamins, which are important for maintaining strength and health during chemotherapy. This substitution can be applied to various recipes, such as oatmeal, mashed potatoes, and smoothies.
Choice D reason: Top Fruits with Yogurt
Topping fruits with yogurt not only increases calorie and protein intake but also adds beneficial probiotics. Yogurt is a good source of protein and calcium, and when combined with fruits, it provides a nutritious and appealing snack or dessert. This combination can help improve appetite and provide essential nutrients needed during chemotherapy.
Choice E reason: Increase Fluids During Meals
Increasing fluids during meals is not specifically aimed at increasing calorie and protein intake. While staying hydrated is important, excessive fluid intake during meals can sometimes lead to a feeling of fullness, which may reduce overall food intake. It is better to focus on nutrient-dense foods and beverages that provide both hydration and essential nutrients.
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