What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube?
Examine each naris for patency and skin breakdown
Place the patient in the high-Fowler's position
Anesthetize the throat
Have the patient take a few sips of water
The Correct Answer is C
Rationale:
A. Examining the nares for patency and skin breakdown is important for safety but does not directly reduce discomfort during insertion.
B. Placing the patient in high-Fowler’s position promotes safe passage and reduces aspiration risk, but it does not specifically relieve discomfort.
C. Anesthetizing the throat (e.g., with a topical anesthetic spray or viscous lidocaine) can numb the mucosa, significantly reducing discomfort during NG tube insertion.
D. Having the patient sip water helps advance the tube once insertion has started, but it does not reduce the initial discomfort of tube passage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Coffee-ground aspirate indicates the presence of partially digested blood, often from gastrointestinal bleeding. The nurse’s priority is to notify the health care provider immediately for further evaluation and intervention.
B. Irrigating the tube with water could worsen bleeding or obscure diagnostic evaluation.
C. Checking tube placement is not the priority when abnormal aspirate indicating bleeding is found.
D. Assessing pH helps confirm placement but does not address the critical finding of possible GI bleeding.
Correct Answer is D
Explanation
Rationale:
A. Infiltration presents with swelling, pallor, coolness, and discomfort due to IV fluid leaking into surrounding tissue, not warmth and erythema.
B. Fluid overload manifests as dyspnea, crackles, edema, and hypertension, not localized site symptoms.
C. Sepsis involves systemic infection signs such as fever, chills, and hypotension, not just localized IV site changes.
D. It presents with tenderness, warmth, erythema, and pain along the vein due to inflammation of the vessel wall.
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