Difficulty: Medium
Average Score: 67%
Simulated
A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take?
Correct answer
D
Rationale
Correct Answer: D - Determine the length of the NG tube to be inserted prior to the procedure.
Rationale: Before inserting an NG tube, the nurse must measure the distance from the client's nostril to the earlobe to the xiphoid process to determine the appropriate length of the tube to be inserted. This measurement helps ensure that the tube reaches the stomach without coiling in the esophagus or being too short to reach the stomach. Proper insertion depth minimizes the risk of complications such as aspiration or discomfort for the client.
Summary:
A: Asking the client to cough while inserting the NG tube is unnecessary and does not contribute to the safe insertion of the tube.
B: Sterile gloves are not required for NG tube insertion unless the client is immunocompromised or during specific circumstances.
C: Placing the client into a left lateral position is not a standard step for NG tube insertion and is not necessary in this scenario.
E, F, G: No information is provided for
Rationale: Before inserting an NG tube, the nurse must measure the distance from the client's nostril to the earlobe to the xiphoid process to determine the appropriate length of the tube to be inserted. This measurement helps ensure that the tube reaches the stomach without coiling in the esophagus or being too short to reach the stomach. Proper insertion depth minimizes the risk of complications such as aspiration or discomfort for the client.
Summary:
A: Asking the client to cough while inserting the NG tube is unnecessary and does not contribute to the safe insertion of the tube.
B: Sterile gloves are not required for NG tube insertion unless the client is immunocompromised or during specific circumstances.
C: Placing the client into a left lateral position is not a standard step for NG tube insertion and is not necessary in this scenario.
E, F, G: No information is provided for