Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric
decompression. Which of the following supplies should the nurse obtain prior to the procedure?
A. Oil-based lubricant
A) Oil-based lubricant: Using oil-based lubricants for nasogastric tube insertion is inappropriate as they can increase the risk of respiratory complications if aspirated. Water-soluble lubricants are preferred because they reduce friction and dissolve easily, minimizing the risk of respiratory aspiration and facilitating a smoother insertion.
B. Enteric feeding pump
B) Enteric feeding pump: An enteric feeding pump is used for administering enteral nutrition, not for gastric decompression. Gastric decompression involves removing gastric contents to relieve pressure, often using a syringe or gravity drainage, making a feeding pump unnecessary for this procedure.
C. Sterile gloves
C) Sterile gloves: Sterile gloves are not required for inserting a nasogastric tube, as this is a clean, not sterile, procedure. Clean gloves are sufficient to maintain infection control standards, ensuring protection against pathogens while allowing for safe tube insertion.
D. pH strips
D) pH strips: pH strips are crucial for verifying the correct placement of a nasogastric tube by checking the acidity of aspirated stomach contents. Ensuring the tube is in the stomach and not the lungs is vital for patient safety, and pH strips provide a reliable method to confirm gastric placement.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
a. Oil-based lubricant
Explanation:
The correct answer is a. Oil-based lubricant.
When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.
Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a different procedure and indication
Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.
Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body fluids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.
By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.
Similar Questions
A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?
A. Check the client's ability to use the call light.
The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.
B. Document the client's risk in the medical record.
While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.
C. Request a referral for physical therapy
Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.
D. Place a gait belt in the client's room.
Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.
Full Explanation
The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.
Explanation for the other options:
b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.
c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.
d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.
A nurse is caring for a client who has a new colostomy. The client tells the nurse, "I don't want anyone to
see me with this bag." Which of the following responses should the nurse make?
A. Many people have colostomies, and they live full lives
When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and offers hope to the client.
B. "Would it help to speak to someone else who has a colostomy?
Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.
C. Why don't you want people to see the colostomy bag?
Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client
D. The colostomy is probably only temporary
The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being
Full Explanation
a. "Many people have colostomies and they live full lives."
Explanation:
The correct answer is a. "Many people have colostomies and they live full lives."
When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and offers hope to the client.
Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.
Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.
Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.
By responding with the statement that many people live full lives with colostomies, the nurse offers support, normalizes the client's experience, and promotes a positive outlook for the client's future.
A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?
A. The client's heart rate is 110/min.
An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
B. The client is guarding their abdominal incision.
Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
C. The client exhibits facial grimacing.
Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
D. The client reports pain.
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Full Explanation
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Explanation for the other options:
a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.
