What should the nurse not do during the removal of an NGT?

Correct Answer: B

Rationale: The correct answer is B because asking the client to take a deep breath and hold it before removing the NGT helps prevent aspiration of the tube contents into the lungs. This action creates positive pressure in the chest, reducing the risk of aspiration. A: Confirming the physician's order is important but not directly related to the physical act of removing the NGT. C: Pinching the tube with a gloved hand is unnecessary and may cause discomfort or damage to the tube. D: Asking the client to exhale while removing the tube may increase the risk of aspiration as it creates negative pressure in the chest.

Correct Answer: B

Rationale: The correct answer is B: Decrease PN rate to 50 mL/hour. This is because as Elise transitions to solid food, her need for parenteral nutrition will decrease. Decreasing the PN rate to 50 mL/hour gradually weans her off PN while ensuring she is still receiving some nutrition. Choice A is incorrect as abruptly discontinuing PN can lead to nutritional deficiencies and potential complications. Choice C is incorrect as starting normal saline is unrelated to the weaning process from PN. Choice D is incorrect as continuing the current infusion rate would not facilitate the transition to solid food.

Correct Answer: A

Rationale: The correct answer is A: Physical activity. Lifestyle-related diseases, such as heart disease and type 2 diabetes, are often linked to common risk factors like smoking, genetics, and poor nutrition. However, physical activity is not a risk factor but rather a protective factor that can help prevent these diseases. Regular exercise can improve cardiovascular health, manage weight, and reduce the risk of chronic conditions. Therefore, physical activity does not fit the criteria of a common risk factor shared by lifestyle-related diseases. Smoking, genetics, and poor nutrition are directly associated with an increased risk of developing such diseases.

Correct Answer: B

Rationale: The correct answer is B: Umbilicus. When performing a rectal procedure, the rectal tip should be directed towards the umbilicus for proper insertion into the rectum. The umbilicus is used as a landmark to guide the rectal tip into the correct position. Directing the tip towards the sigmoid (A) or large intestine (D) would be incorrect as it may lead to improper insertion. Choosing the rectum (C) is not specific enough as the rectal tip needs to be aimed towards a more precise point for accurate placement.

Correct Answer: C

Rationale: The correct nursing diagnosis of "Excessive fluid volume" takes highest priority for the client with chronic renal failure due to the presenting signs and symptoms of fluid overload: high blood pressure, neck vein distention, and bibasilar crackles indicating fluid in the lungs. Managing fluid volume is crucial to prevent complications such as pulmonary edema and worsening renal function. Fear (A) is not the priority as physiological needs should be addressed first. Urinary retention (B) is not the priority as the client's symptoms are more indicative of fluid overload rather than urinary retention. Self-care deficient: Toileting (D) is not the priority as it does not address the immediate physiological threat posed by excessive fluid volume.