he nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Instruct the client to place his chin to his chest and swallow.

Withdraw the tube if the client gags during insertion.

Place the client in a supine position.

Measure the tube for insertion from the tip of the nose to the umbilicus.

Answer and Explanation

The Correct Answer is A

a. Instruct the client to place his chin to his chest and swallow: This technique helps facilitate the passage of the nasogastric tube through the pharynx and into the esophagus.

b. Withdraw the tube if the client gags during insertion: Gagging is a normal response, and

withdrawing the tube may lead to repeated attempts and discomfort for the client. Encouraging the client to swallow can help overcome the gag reflex.

c. Place the client in a supine position: The client is usually positioned in a semi-Fowler's position or upright to ease tube insertion and minimize the risk of aspiration.

d. Measure the tube for insertion from the tip of the nose to the umbilicus: The proper

measurement for nasogastric tube insertion is typically from the tip of the nose to the earlobe and then down to the xiphoid process, not the umbilicus.

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Correct Answer is D

Explanation

a. "The pain radiates down to my lower back." This statement is not typical of peptic ulcer

disease. Radiation of pain to the lower back may suggest other abdominal or musculoskeletal issues.

b. "I feel so much better after eating." Relief of pain after eating is more indicative of gastric ulcer rather than peptic ulcer disease. Peptic ulcers are often associated with pain that worsens after eating.

c. "My pain is relieved by having a bowel movement." Relief of pain with bowel movements is

not a characteristic finding of peptic ulcer disease. This may suggest other gastrointestinal issues.

d. "The pain is worse after I eat a meal high in fat." This statement is consistent with peptic ulcer disease. High-fat meals stimulate gastric acid secretion, potentially exacerbating the pain

associated with peptic ulcers.

A. "Use the provided towelette to cleanse the area by moving in a back-and-forth motion." B. "It will be easier to use your nondominant hand to spread the labia." C. "Start the flow of urine before passing the container under the stream to collect the specimen." D. "Remove the specimen container before stopping the stream of urine"

Correct Answer is A

Explanation

Choice A Rationale: The correct method for cleansing the area before collecting a midstream urine specimen is to wipe from front to back, not back-and-forth. This is to avoid contamination of the specimen with bacteria from the anal area. The towelette should be used in a single stroke and then discarded to ensure cleanliness.

Choice B Rationale: Using the nondominant hand to spread the labia is a standard practice that allows the dominant hand to manipulate the collection container. This technique helps to prevent contamination of the specimen by keeping the container away from the body and ensuring a clean catch.

Choice C Rationale: It is important to start the flow of urine before collecting the specimen to ensure that the 'midstream' urine is captured. This helps to flush out any bacteria that may be present at the opening of the urethra, reducing the risk of contaminating the sample.

Choice D Rationale: The specimen container should be removed from the stream before stopping the flow of urine to avoid contamination. The initial and final parts of the urine stream can carry bacteria from the urethra and skin, so only the midstream should be collected in the container.

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he nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain.Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

Correct Answer is D

Explanation

charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

Correct Answer is A

Explanation

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