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 C

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 B

Explanation

A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.

A. Reduce the amount of pressure being applied on the top of the foot. B. Palpate the site on the inner side of the ankle below the medial malleolus. C. Obtain a doppler stethoscope to auscultate the pulse at the same site. D. Document in the nurses' notes that the dorsalis pedis pulse is not palpable.

Correct Answer is A

Explanation

A. Reducing the amount of pressure applied is the appropriate next step because excessive pressure can occlude the pulse, making it difficult to feel. Lightening the pressure may help the nurse detect the pulse.
B. Palpating the posterior tibial pulse (below the medial malleolus) is another option if the dorsalis pedis pulse is not palpable, but it should be attempted only after ensuring that proper technique was used to feel the dorsalis pedis pulse.
C. Using a Doppler stethoscope is a good option if the pulse remains non-palpable after proper technique has been used. However, it is not the immediate next step.
D. Documenting that the dorsalis pedis pulse is not palpable should be done after all appropriate steps, including adjusting the pressure and possibly using a Doppler, have been attempted.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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