MS Lab 4 - NG/GI

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?

"Take a deep breath when I tell you, and hold it while I remove the tube."

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? A. Examine each naris for patency and skin breakdown. B. Place the patient in the high-Fowler's position. C. Anesthetize the throat. D. Have the patient take a few sips of water.

A. Examine each naris for patency and skin breakdown.

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure?

Using oil-soluble lubricant would indicate further teaching. Use water-based lubricant instead.

A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1. Elevate HOB to at least 30 degrees. 2. Check for gastric residual volume. 3. Flush tubing with 30 ml of water. 4. Verify tube placement. 5. Initiate feeding.

1, 4, 2, 3, 5

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? A. 3.5 B. 7.0 C. 7.35 D. 7.5

A. 3.5

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A. A 28-year-old patient who fractured a femur after heavy drinking. B. A 73-year-old patient who is on anticoagulation therapy. C. A 54-year-old patient who broke a cheekbone in a fall. D. A 67-year-old patient with a history of unexplained nosebleeds.

A. A 28-year-old patient who fractured a femur after heavy drinking.

The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. A. Check the residual volume. B. Aspirate the stomach contents. C. Turn off the suction to the nasogastric tube. D. Remove the tube and place it in the other nostril. E. Test the stomach contents for a pH of less than 3.5.

A. Check the residual volume. B. Aspirate the stomach contents. C. Turn off the suction to the nasogastric tube. D. Test the stomach contents for a pH of less than 3.5.

Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? A. Positioning the patient in a high-Fowler's position B. Assessing the patient's abdomen for bowel sounds C. Determining any history of unexplained nosebleeds D. Educating the patient about the need for the intervention

A. Positioning the patient in a high-Fowler's position

The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate insertion of the tube?

Asking the client to swallow as the tube is being advanced

A client's nasogastric feeding tube has become clogged. The nurse should take which action first?

Aspirate the tube.

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action?

Assess tube placement.

The nurse in concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is the priority? A. Observe the color of gastric contents. B. Verify tube placement before feeding. C. Add blue coloring to enteral formula. D. Run the formula over 12 hours to decrease overload.

B

The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain? A. 10-ml Luer-Lock syring B. Asepto syringe C. Sterile gloves D. Double gloves

B

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? A. Call the health care provider (HCP). B. Place the tube in a bottle of sterile water. C. Immediately replace the chest tube system. D. Place a sterile dressing over the disconnection site.

B. Place the tube in a bottle of sterile water.

What would the nurse use to irrigate a patient's nasogastric tube after providing medications? A. Coffee B. Purified water C. Tea D. Apple juice

B. Purified water

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? A. Ask the patient to cough. B. Withdraw the tube to the nasopharynx. C. Encourage the patient to swallow. D. Instruct the patient to hyperextend the neck.

B. Withdraw the tube to the nasopharynx.

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a nasogastric (NG) tube? A. "Remember to aspirate 5 mL to 10 mL of stomach contents before flushing the tube." B. "Let me know if the patient complains of anything related to the NG tube's placement." C. "Tell me if you see any vomit in the patient's mouth during oral care." D. "Please see if the NG tubing has advanced at all."

C. "Tell me if you see any vomit in the patient's mouth during oral care."

When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next? A. Nothing, since this is an expected pH value B. Advance the tube C. Anticipate a chest x-ray D. Pull back on the tube

C. Anticipate a chest x-ray

What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube? A. Listen to bowel sounds. B. Listen to lung sounds. C. Check NG tube placement. D. Turn the patient onto his or her left side.

C. Check NG tube placement.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? A. Position the client supine to assist in medication absorption. B. Aspirate the nasogastric tube after medication administration to maintain patency. C. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. D. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

C. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? A. Physical care technique B. Activity of daily living C. Indirect measure of care D. Lifesaving measure

C. Indirect measure of care

What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture? A. Check the tube placement. B. Assess the pH of the contents. C. Notify the health care provider. D. Irrigate the tube with water.

C. 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? A. Ask another nurse to attempt the insertion. B. Document the attempts in the patient's medical record. C. Notify the physician that the attempts were unsuccessful. D. Allow the patient to rest for 30 minutes before resuming the process.

C. Notify the physician that the attempts were unsuccessful.

The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? A. Mark the tube at 10 inches. B. Mark the tube at 32 inches. C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. D. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

Checking for the presence of bowel sounds in all 4 quadrants

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? A. From the tip of the nose to the earlobe. B. From the tip of the earlobe to the xiphoid process. C. From the tip of the earlobe to the nose to the xiphoid process. D. From the tip of the nose to the earlobe to the xiphoid process.

D

The patient is to receive medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? A. Instill nonliquid medications without diluting. B. Irrigate the tube with 60ml of water after all medications are given. C. Mix all medications together to decrease the number of administrations. D. Check with the pharmacy for availability of the liquid forms of medications.

D

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action? A. Quickly insert the tube. B. Notify the health care provider immediately. C. Remove the tube and reinsert when the respiratory distress subsides. D. Pull back on the tube and wait until the respiratory distress subsides.

D. Pull back on the tube and wait until the respiratory distress subsides.

The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action?

Pull back on the tube, and wait until the client is breathing easily.