Fundamentals Exam 3

A client scheduled for the removal of a nasogastric (NG) tube asks the nurse, 'Will taking out the tube hurt?' How will the nurse respond?

"You may experience minor discomfort as the tube is being removed"

Place in the correct order the process to verify the placement of the nasogastric tube. Use all options

1)Measure exposed length of tube.2)Attach syringe to tube and aspirate 6 ml of gastric secretions.3)Measure pH using appropriate testing strips.4)Flush the tube with 30 to 50 ml of water.5)Remove syringe and attach to feeding delivery set.

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options.

1)Place the client in high Fowler position.2)Measure the intended length to insert the NG tube.3)Lubricate the tube tip with water-soluble lubricant.4)Direct the tube upward and backward along the floor of the nose.5)Instruct the client to place the chin onto the chest.6)Advance the tube while the client swallows.

The nurse is preparing to administer an intermittent feeding to a client who has a nasogastric feeding tube. Place the following steps in the correct order. Use all options.

1)Position the client with the head of bed elevated 30 to 45° degrees. 2)Verify correct tube placement. 3)Aspirate all gastric contents. 4)Verify that residual volume is less than 200 mL. 5)Flush the tube with 30 mL of water. 6)Administer the feeding.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. At what level does the nurse place the feeding bag on the pole?

12 in (30 cm) above the stomach.

The nurse is providing a continuous tube feeding for a client. At what angle will the nurse place the head of the bed during the feeding?

30-45 degrees

The nurse has finished aspirating the gastric contents before administering a prefilled, continuous tube feeding. At this point in the procedure, how much water does the nurse use to flush the tube?

30mL

The nurse is caring for a client who had a gastrostomy tube placed 24 hours ago. While assessing and changing the dressing, the nurse will ensure the gastrostomy tube is rotated at least how many degrees?

360 degrees

A nurse is checking a client's nasogastric tube aspirate before administering the prescribed medication. Which pH reading does the nurse find concerning?

6.0

The nurse is caring for a client who is receiving a continuous tube feeding. Which accurately describes an aspect of this procedure?

A feeding pump is used for a continuous feeding.

The nurse prepares to provide gastrostomy insertion site care. The gastrostomy tube was placed this week. The client reports pain at the site. Which action does the nurse take next?

Administer pain medication

The nurse provides the client with a gravity feeding via a gastrostomy tube. Which action is most appropriate for the nurse to ensure is accomplished?

Allow the feeding to infuse slowly from the feeding bag

A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. On inspection the nurse finds a great deal of slack in the tube. Which action will the nurse take next?

Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

The nurse has just confirmed proper placement of a nasogastric tube. Which action will the nurse take next?

Apply skin barrier to the tip and end of the nose.

The nurse notes the health care provider has written an order to discontinue a client's nasogastric (NG) tube. Which action will the nurse to do perform?

Ask the client to take a deep breath and pull out the tube quickly and carefully.

A nurse enters a client's room to perform a tube feeding. Which nursing action will the nurse perform first?

Aspirate stomach contents and check pH

client has had a nasogastric tube inserted in preparation for tube feedings. When developing the client's plan of care, the nurse anticipates checking the placement of the tube at which time?

Before administering a medication through the tube

The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action will the nurse take?

Connect a syringe filled with warm water to the feeding tube and flush the tube using gentle pressure.

The health care provider has written a prescription for a client's nasogastric (NG) tube to be removed. Which action will the nurse do first?

Discontinue the suction.

The nurse is administering an intermittent tube feeding to a client via gravity using an open feeding bag system. What step will the nurse perform when the feeding bag is empty?

Flush the feeding bag with 30 mL water.

A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric (NG) tube. Which finding contraindicates placement of a NG tube by the nurse in this client?

History of facial fractures

The nurse is preparing to remove a client's nasogastric (NG) tube. In what position will the nurse place this client prior to removing the NG tube?

In an upright position with the bedrail nearest the nurse down.

The nurse, removing a nasogastric (NG) tube from a client, flushes the NG tube prior to removing it. Which is the appropriate action for the nurse to take?

Instill 30 to 50 mL of air to clear the tube.

The nurse is caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action is appropriate to address this concern?

Notify the health care provider for a prescription to apply an antifungal powder.

The nurse performs gastrostomy site care and notes drainage. What action does the nurse take?

Place a gauze dressing under the external bumper.

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse requires intervention by the charge nurse?

Places the client in the left lateral recumbent position

The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what action does the nurse do next?

Proceed with nasogastric tube placement.

A nurse is concerned the end of a client's nasogastric tube is in the wrong location. Which method is most reliable for the nurse to verify the correct placement of the tube?

Radiographic confirmation of position

The nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method will the nurse use to increase the flow rate of the formula?

Raise the height of the syringe.

Following insertion of a nasogastric (NG) tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take?

Secure the tubing with a safety pin to the client's gown at shoulder level.

The nurse is checking on a client who has just completed receiving a tube feeding. Which action does the nurse now instruct the client to take?

Sit up for 1 hour.

The nurse has inserted a nasogastric tube in a client per orders. Which action will the nurse accomplish next?

Test the pH of aspirated content.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which has likely occurred?

The NG tube is in the client's airway.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. After checking tube placement, which action will the nurse take next?

check residual

The client is receiving a continuous tube feeding using a feeding pump. How often should the nurse plan to check for gastric residual in this client?

every 4-6 hours

The nurse is caring for a client who has a continuous tube feeding. How often will the nurse confirm placement of the tube?

every 4-6 hours

The nurse has returned to a client's bedside of whom a nasogastric (NG) tube was removed 2 hours earlier. Which assessment will the nurse perform at this time?

gastric distention

The nurse has completed inserting a nasogastric (NG) tube in a client. Which documentation will the nurse ensure is added to the client's record?

measurement of the exposed tube

After putting on gloves, the nurse lubricates the nasogastric (NG) tube prior to insertion into the client's nares. Which lubricant is appropriate to use?

water soluble lubricant

After measuring from the client's nostril to the ear lobe, how does the nurse continue to measure the length of the nasogastric (NG) tube to be inserted for a client?

xiphoid process