Which is the best approach to change nasogastric tube tape that has become crusted with secretions?
Soak the crusted areas of tape with adhesive remover.
Saturate the tape with a denatured alcohol solution.
Use blunt-edged scissors to loosen the tape from the skin.
Soften the secretions using a warm moist washcloth.
The Correct Answer is D
Choice A reason: This is an incorrect choice because soaking the crusted areas of tape with adhesive remover is not the best approach to change nasogastric tube tape that has become crusted with secretions. Adhesive remover is a solvent that can dissolve the glue that holds the tape to the skin. However, it can also irritate the skin and cause redness, burning, or allergic reactions. The nurse should avoid using adhesive remover on the patient's face, especially near the eyes, nose, or mouth.
Choice B reason: This is an incorrect choice because saturating the tape with a denatured alcohol solution is not the best approach to change nasogastric tube tape that has become crusted with secretions. Denatured alcohol is a mixture of ethanol and other chemicals that can dissolve the glue that holds the tape to the skin. However, it can also dry out the skin and cause cracking, peeling, or bleeding. The nurse should avoid using denatured alcohol on the patient's face, especially near the eyes, nose, or mouth.
Choice C reason: This is an incorrect choice because using blunt-edged scissors to loosen the tape from the skin is not the best approach to change nasogastric tube tape that has become crusted with secretions. Blunt-edged scissors are scissors that have rounded tips instead of sharp points. They can be used to cut the tape without injuring the skin. However, they can also pull or tug on the skin and cause pain, discomfort, or damage. The nurse should avoid using scissors on the patient's face, especially near the eyes, nose, or mouth.
Choice D reason: This is the correct choice because softening the secretions using a warm moist washcloth is the best approach to change nasogastric tube tape that has become crusted with secretions. A warm moist washcloth is a cloth that is soaked in warm water and wrung out. It can be applied gently to the crusted areas of tape to soften the secretions and loosen the tape from the skin. It can also soothe the skin and prevent irritation or infection. The nurse should use a clean washcloth for each application and discard it after use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because sleep-wake pattern is not the most important assessment to determine if a patient is receiving sufficient sleep. Sleep-wake pattern is the cycle of sleeping and waking that follows a circadian rhythm. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep-wake patterns that suit their needs and preferences.
Choice B reason: This is an incorrect choice because hours of sleep each night is not the most important assessment to determine if a patient is receiving sufficient sleep. Hours of sleep each night is the duration of sleep that a person gets in a 24-hour period. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep needs and requirements that vary according to age, lifestyle, health, and other factors.
Choice C reason: This is the correct choice because whether the patient feels rested is the most important assessment to determine if a patient is receiving sufficient sleep. Feeling rested is the subjective perception of the patient about their sleep quality and quantity. It is a reliable indicator of sleep sufficiency, as it reflects the patient's satisfaction and well-being after sleeping.
Choice D reason: This is an incorrect choice because frequency of nocturia is not the most important assessment to determine if a patient is receiving sufficient sleep. Frequency of nocturia is the number of times that a person has to urinate at night. However, it is not a reliable indicator of sleep quality or quantity, as it may be influenced by other factors such as fluid intake, medication, or medical conditions.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because the axillary method is not the most accurate measurement of the core temperature. The axillary method involves placing a thermometer under the patient's armpit and measuring the temperature of the skin surface. This method can be affected by factors such as sweating, clothing, and ambient temperature. The axillary method can underestimate the core temperature by 0.5°C to 1.5°C¹.
Choice B reason: This is an incorrect choice because the oral method is not the most accurate measurement of the core temperature. The oral method involves placing a thermometer in the patient's mouth and measuring the temperature of the sublingual pocket. This method can be affected by factors such as eating, drinking, smoking, and mouth breathing. The oral method can underestimate the core temperature by 0.3°C to 0.8°C¹.
Choice C reason: This is the correct choice because the rectal method is the most accurate measurement of the core temperature. The rectal method involves inserting a thermometer into the patient's rectum and measuring the temperature of the rectal mucosa. This method reflects the temperature of the blood flowing through the core of the body. The rectal method is considered the gold standard for measuring the core temperature¹.
Choice D reason: This is an incorrect choice because the forehead method is not the most accurate measurement of the core temperature. The forehead method involves placing a thermometer on the patient's forehead and measuring the temperature of the temporal artery. This method can be affected by factors such as sweating, hair, and ambient temperature. The forehead method can overestimate or underestimate the core temperature by 0.5°C to 1°C¹.
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