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

Explanation

A. It is essential for the nurse to develop self-awareness of their personal values to avoid imposing these values on the client. As an advocate, the nurse's primary role is to represent the client's wishes and ensure they are respected, regardless of the nurse's personal beliefs or values.
B. While challenging differing opinions may sometimes be necessary, it is more important to ensure the client's wishes are clearly communicated rather than simply opposing differing views.
C. Educating the client on relevant nursing literature is not the primary role of advocacy in this context. The focus should be on the client’s values and wishes rather than on influencing them with professional literature.
D. Listening to discussions is important, but the nurse's role as an advocate is to ensure the client's voice is heard during the discussions, rather than informing the client of decisions after the fact.

A. Apply a barrier ointment to intact areas that may be exposed to moisture. B. Determine the size and depth of skin breakdown over the sacral area. C. Complete a functional assessment of the client's self-care abilities. D. Establish a toileting schedule to decrease episodes of incontinence.

Correct Answer is B

Explanation

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

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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 nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?

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