Nokea
The nurse inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, but as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which action if taken by the nurse at this point would indicate a need for further instruction regarding the insertion of an NG tube?
- A. Pulling the tube back slightly
- B. Instructing the client to breathe slowly
- C. Continuing to advance the tube to the desired distance
- D. Checking the back of the pharynx using a tongue blade and flashlight
Correct Answer: C
Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. The nurse should check the back of the pharynx using a tongue blade and flashlight to check for coiling and then pull the tube back slightly to prevent entrance into the larynx. Slow breathing helps the client relax to reduce the gag response.
You may also like to solve these questions
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to report?
- A. Amenorrhea
- B. Menorrhagia
- C. Metrorrhagia
- D. Dysmenorrhea
Correct Answer: A
Rationale: Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease.
A prenatal client is being evaluated for possible gestational diabetes. Which data identified and documented after the client's initial nursing assessment would support that diagnosis?
- A. 22 years old
- B. A gravida 4, para 0, aborta 3
- C. 5^{\prime} 6^{\prime \prime tall, weighs 130 pounds
- D. Stated, 'I get really tired after working all day'
Correct Answer: B
Rationale: A history of unexplained stillbirths or miscarriages puts the client at high risk for gestational diabetes. Fatigue is a normal occurrence during pregnancy. The client's height (5'6†tall) and weight (130 pounds) do not meet the criteria of 20% over ideal weight. Therefore, the client is not obese, a possible factor related to gestational diabetes. To be at high risk for gestational diabetes, the maternal age should be greater than 25 years.
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
- A. Abnormal involuntary flexion of the extremities
- B. Abnormal involuntary extension of the extremities
- C. Upper extremity extension with lower extremity flexion
- D. Upper extremity flexion with lower extremity extension
Correct Answer: B
Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? Select all that apply.
- A. Dyspnea
- B. Flat neck veins
- C. Nausea and vomiting
- D. Chest pain or discomfort
- E. Hypotension and dizziness
- F. Hypertension and headache
Correct Answer: A,D,E
Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Neither headache nor nausea and vomiting are associated with the effects of uncontrolled atrial fibrillation.
A client prescribed warfarin sodium has been instructed to limit the intake of foods high in vitamin K. The nurse determines that the client understands the instructions if the client indicates that which food items need to be avoided? Select all that apply.
- A. Tea
- B. Turnips
- C. Oranges
- D. Cabbage
- E. Broccoli
- F. Strawberries
Correct Answer: A,B,D,E
Rationale: Warfarin sodium is an anticoagulant that interferes with the hepatic synthesis of vitamin K-dependent clotting factors. The client is instructed to limit the intake of foods high in vitamin K while taking this medication. These foods include coffee or tea (caffeine), turnips, cabbage, broccoli, greens, fish, and liver.