Acute Lab Quiz
How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition?
Check the gastric residual volume
A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response?
Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a nasogastric (NG) tube?
"Tell me if you see any vomit in the patient's mouth during oral care"
Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?
"Tell me when and how much the patient first voids"
Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots?
Increase the irrigation drip rate
What will the nurse need before removing a patient's nasogastric tube?
A health care provider's order
While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next?
Keep the catheter in place, and begin again with a new sterile catheter
What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture?
Notify the health care provider
What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares?
Notify the physician that the attempts were unsuccessful
Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube?
Positioning the patient in a high-Fowler's position
What would the nurse use to irrigate a patient's nasogastric tube after providing medications?
Purified water
Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter?
Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy?
"Alert me immediately if you see any blood in the fecal matter in the pouch"
The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective?
"I'll help keep his legs away from the sterile field."
Which patient does not have a medical condition that contraindicates placement of a nasogastric tube?
A 28-year-old patient who fractured a femur after heavy drinking
Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding?
Elevating the head of the bed reduces the risk for aspiration
Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation?
"Measure and report the patient's temperature to me every 4 hours"
Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances
"Please direct the light to better illuminate the patient's perineal area"
During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first?
Examine the drainage tubing for clots, sediment, and kinks
When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next?
Anticipate a chest x-ray
What is the nurse's initial action when preparing to change a patient's colostomy pouching system?
Applying clean gloves
When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma?
Avoiding unnecessary changes of the pouching system
What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube?
Check NG tube placement
Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter?
Checking the documentation for the volume of fluid used to inflate the balloon
Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter?
Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter
Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter?
Cleanse the urinary meatus daily
While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?
Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra
What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube?
Examine each naris for patency and skin breakdown
Which is not an expected outcome on a first voiding after catheter removal?
Fever and back pain
Which initial nursing action would best help the patient learn self-care of a colostomy pouching system?
Giving the patient a handheld mirror to watch the nurse provide care
When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?
Lubricate the first 5 to 7 inches of the catheter
The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?
Measure and empty the urine
After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take?
Obtain a product designed to unclog NG tubes
What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr?
Plan to check the feeding for completion within the next 3 hours
When pouching a patient's colostomy, which action reduces the patient's risk for injury?
Protecting the skin from irritation caused by fecal drainage
How might the nurse minimize the patient's anxiety when removing a nasogastric tube?
Provide reassurance of what will happen during the procedure and talk the patient through the process
What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed?
Providing the patient with mouth care
The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?
Remove soiled gloves, and perform hand hygiene
While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection?
Replace all contaminated supplies, and begin the process again
Which nursing action is appropriate when feeding gastric residual is 50 mL?
Return it to the stomach via the feeding tube
Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?
The excess catheter tubing has been coiled beside the patient's inner thigh
Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter?
The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique
Why does the nurse clamp the nasogastric tube before removing it from a patient?
To keep any fluid from flowing out
What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter?
To promote relaxation
Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter?
To reduce the patient's risk of urinary tract infection
When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication?
Urinary tract infection (UTI)
Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation?
Use slow, even pressure when injecting the irrigating fluid
Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?
Use the smallest size catheter possible
What would minimize the nurse's risk for contamination during the removal of a nasogastric tube?
Wearing treatment gloves
What would the nurse do if he or she encountered resistance when inserting a nasogastric tube?
Withdraw the tube to the nasopharynx
