Difficulty: Medium
Average Score: 80%
Simulated
Passage / Scenario
Client receiving nasogastric tube; Client with chest tube; Client for lumbar puncture; Client post-esophagogastroduodenoscopy.A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?
Correct answer
A
Rationale
The correct answer is A because elevating the head of the client's bed to 30┬░ before inserting a nasogastric tube helps prevent aspiration by promoting proper positioning and facilitating tube insertion. Elevating the head of the bed reduces the risk of the tube entering the trachea instead of the esophagus. Choices B, C, and D are incorrect because maintaining the chest tube below the insertion site when ambulating, assisting the client into a fetal position for a lumbar puncture, and assessing gag reflex post-procedure are all appropriate and safe nursing actions that do not require intervention.