According to Chelsea's BMI of 17, she would be classified as?

Choice A rationale

Breathing in and out normally does not protect the airway during nasogastric tube removal. The risk of aspiration is present as the tube is withdrawn, and normal breathing does not actively close off the trachea.

Choice B rationale

Taking a deep breath and coughing can help to clear the airway after the tube is removed but does not directly aid in preventing aspiration during the removal process itself. Coughing expels material from the lungs and throat.

Choice C rationale

Holding her breath during nasogastric tube removal helps to close the epiglottis, which covers the trachea. This action minimizes the risk of aspiration of any residual secretions or reflux that might occur as the tube is being withdrawn.

Choice D rationale

Bearing down, or performing the Valsalva maneuver, increases intra-abdominal pressure and is typically used to stimulate a bowel movement. It is not relevant to protecting the airway during nasogastric tube removal and could potentially increase the risk of reflux.

Choice A rationale

Light palpation is typically performed after auscultation to assess for superficial tenderness, muscle tone, and pulsations. Auscultation precedes palpation to avoid inducing artificial bowel sounds or altering existing ones due to manual pressure.

Choice B rationale

Auscultation of bowel sounds in all four quadrants is the next step in the abdominal assessment after inspection. Listening to bowel sounds provides information about the motility of the gastrointestinal tract and should be done before palpation or percussion, which can alter these sounds.

Choice C rationale

Percussion for tones in all four quadrants is usually performed after auscultation and before palpation. Percussion helps to assess the size and density of abdominal organs and to identify the presence of fluid or air.

Choice D rationale

Deep palpation is performed last in the abdominal assessment sequence to evaluate for deeper masses and aortic pulsations. It follows inspection, auscultation, and light palpation, allowing the nurse to gather preliminary information before applying deeper pressure. .