The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

Use firm pressure to pass the tube through the glottis.

Have the client tilt head backward to open the passage.

Give the client a few sips of water to drink.

Remove the tube and attempt reinsertion.

Answer and Explanation

The Correct Answer is D

A. Using firm pressure to pass the tube through the glottis can cause discomfort and potentially damage the client's airway. It is important to proceed with caution and avoid causing harm.
B. Tilting the head backward can actually make the insertion more difficult and increase the risk of gagging or aspiration. Proper head positioning typically involves slight flexion.
C. Giving the client sips of water is not recommended during NGT insertion as it can exacerbate gagging and increase the risk of aspiration.
D. Removing the tube and attempting reinsertion is the appropriate action if the client begins to gag. It allows the nurse to reposition the tube and attempt insertion more gently, ensuring the tube is correctly placed without causing undue discomfort or harm.

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Correct Answer is ["A","B","D"]

Explanation

A. Hand tremors can impair the client’s ability to safely and effectively perform fine motor tasks, such as toenail care, making it necessary to assign a UAP for this task.
B. A shuffling gait suggests a mobility issue, which may make it difficult for the client to safely bend over and care for their feet, increasing the risk of falls or improper foot care.
C. Urinary incontinence does not directly impact the client’s ability to perform foot care and is not a reason to assign a UAP for this task.
D. Diminished visual acuity affects the client’s ability to see clearly, which is crucial when performing tasks like toenail care to avoid injury.
E. Syncope when bending indicates a risk of fainting, but it is not specifically related to the need for routine foot care by a UAP.

A. Dizziness can occur during cleansing. B. Foreskin should not be retracted. C. An erection may occur while providing care. D. Pubic area should be kept shaved.

Correct Answer is B

Explanation

A. Dizziness during perineal cleansing is not a common concern and should not be included as a standard part of perineal care instructions.
B. For male clients, the foreskin should be retracted gently if it is retractable to clean the area underneath. However, if the foreskin is not retractable or if retraction causes discomfort, it should not be forced. This instruction is crucial for proper hygiene and prevention of infection.
C. While an erection can occur, it is not a standard concern to highlight during perineal care education. The focus should be on proper technique and hygiene.
D. Shaving the pubic area is not necessary for perineal care and can potentially cause irritation or increase the risk of infection. Proper hygiene practices are more important than hair removal.

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The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is B

Explanation

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