a nurse is preparing to remove a nasogastric tube from a client the nurse would instruct the client to do which of the following just before the nurse
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?

Correct answer: B

Rationale: When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.

2. Christina is receiving an enteral feeding that requires a concentration of 80ml of supplement mixed with 20 ml of water. How much water do you mix with an 8 oz (240ml) can of feeding?

Correct answer: A

Rationale: For an 8 oz (240 ml) can of feeding, mix 60 ml of water to achieve the required concentration.

3. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:

Correct answer: D

Rationale: The purpose of the Jackson-Pratt drain is to prevent the accumulation of drainage in the wound after an abdominal resection.

4. A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?

Correct answer: B

Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

5. The nurse is monitoring a client for the early signs and symptoms for dumping syndrome. Which symptom indicates this occurrence?

Correct answer: C

Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

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