A nurse positions a patient for the insertion of a nasogastric (NGT) tube by:
Side-lying with head of bed (HOB) at 30 degrees.
In the tripod position; leaning over the over the bed table on the left side with chin-to-chest.
Sitting the patient in an upright position.
Sitting the patient in an upright position and hyperextending the patient's head.
The Correct Answer is C
Choice A rationale
The side-lying position with the head of bed at 30 degrees does not optimally align the nasal passages with the esophagus, increasing the risk of the NGT entering the trachea. Proper alignment facilitates easier and safer insertion into the stomach.
Choice B rationale
The tripod position is typically used for patients experiencing respiratory distress to maximize lung expansion. It does not provide the necessary head and neck alignment for safe nasogastric tube insertion.
Choice C rationale
Sitting the patient in an upright position, ideally between 45 to 90 degrees, uses gravity to aid the passage of the NGT down the esophagus. This position also allows the patient to cough effectively if the tube inadvertently enters the trachea.
Choice D rationale
Hyperextending the patient's head during NGT insertion can close off the esophagus and open the trachea, significantly increasing the risk of misplacement of the tube into the respiratory tract. The neck should be flexed forward with the chin to the chest during insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.17"]
Explanation
Step 1: The ordered dose is 17 units.
Step 2: The concentration of the insulin is 100 units/mL.
Step 3: To find the volume to administer, divide the ordered dose by the concentration: 17 units ÷ 100 units/mL = 0.17 mL.
Final answer: The nurse will administer 0.17 mL.
Correct Answer is ["B","E","C"]
Explanation
Choice A rationale
Hyperresonance is a booming sound elicited during percussion, typically heard over hyperinflated lung tissue, such as in emphysema or pneumothorax. In the abdominal assessment, hyperresonance is generally not an expected finding and may indicate gaseous distension.
Choice B rationale
Flatness is a dull, very soft sound with a short duration, usually heard over dense tissues such as bone or muscle. In the abdomen, flatness is not a typical percussion sound and might be elicited over a large tumor or organomegaly.
Choice C rationale
Dullness is a thud-like sound with a medium intensity and duration, typically heard over solid organs such as the liver, spleen, or a distended bladder. In the abdominal assessment, dullness is an expected finding over these organs.
Choice D rationale
Resonance is a hollow sound of moderate duration and low pitch, typically heard over normal lung tissue. Resonance is not an expected percussion sound in the abdominal assessment; tympany and dullness are the predominant sounds.
Choice E rationale
Tympany is a drum-like sound with high pitch and longer duration, commonly heard over air-filled structures such as the stomach and intestines. Tympany is the predominant percussion sound expected over most of the abdomen due to the presence of gas in the gastrointestinal tract.
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