A nurse is inserting a nasogastric (NG) tube for an adult client. ...

[wenmo]

A nurse is inserting a nasogastric (NG) tube for an adult client. During the procedure, the client begins to cough and have difficulty breathing. The priority action at this time is which of the following?
 
  1. Quickly insert the NG tube.
  2. Remove the tube, and notify the physician.
  3. Remove the tube, and reinsert when the client fully recovers.
  4. Pull back on the tube, and wait until the client is breathing easily.

Question 2

The client who is seropositive for human immunodeficiency virus (HIV) has been taking stavudine (d4T, Zerit XR). The nurse assesses which of the following most closely while the client is taking this medication?
 
  1. Appetite
  2. Gastrointestinal function
  3. Presence of paresthesia
  4. Level of consciousness (LOC)

[6ana001]

Answer to Question 1

4

Rationale: If the client experiences difficulty breathing or any respiratory distress during inser-tion of an NG tube, the nurse would pull back the tube and wait until the distress subsides. Re-move the tube, and notify the physician and remove the tube, and reinsert when the client fully recovers describe actions that are unnecessary. Quickly insert the NG tube is dangerous be-cause it is likely that the tube has entered the bronchus.

Answer to Question 2

3

Rationale: Stavudine is an antiretroviral (protease inhibitor) used in the management of HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy; the nurse should closely monitor the client's gait and ask the client about paresthesia. Appetite, gastrointestinal, and level of consciousness (LOC) are not a concern.

[wenmo]

Excellent

[parshano]

TYSM