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?
A.
Elevates the head of the client’s bed to 30° before inserting a nasogastric tube
B.
Assists the client into a fetal position on his side in preparation for a lumbar puncture
C.
Assesses the client’s gag reflex following an esophagogastroduodenoscopy
D.
Maintains the chest tube collection device below the level of the insertion site when ambulating the client
The Correct Answer is A
The action that requires intervention by the charge nurse is:
C. Assesses the client’s gag reflex following an esophagogastroduodenoscopy
Explanation:
- A. Elevates the head of the client’s bed to 30° before inserting a nasogastric tube is an appropriate action. Elevating the head of the bed helps reduce the risk of aspiration and facilitates tube insertion.
- B. Assists the client into a fetal position on his side in preparation for a lumbar puncture is correct. The fetal position helps to open up the vertebral spaces and facilitates the lumbar puncture procedure.
- C. Assesses the client’s gag reflex following an esophagogastroduodenoscopy (EGD) is incorrect. After an EGD, the gag reflex is typically assessed before the client is allowed to eat or drink to ensure that it has returned, as the reflex may be temporarily diminished due to sedation or local anesthesia. Failure to assess the gag reflex can lead to the risk of aspiration.
- D. Maintains the chest tube collection device below the level of the insertion site when ambulating the client is correct. Keeping the collection device below the insertion site ensures proper drainage and prevents backflow into the pleural space.