Week 12 & 13 Foundations Clinical Quiz

1. How can the nurse best minimize a patient's risk for infection during tracheostomy care? A. Adhere to sterile technique when appropriate. B. Frequently assess for signs of local or systemic infection. C. Monitor for indications that tracheostomy care is needed. D. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.

A. Adhere to sterile technique when appropriate Rationale: Adherence to sterile technique is the most important factor in minimizing the patient's risk for infection during tracheostomy care. Proper assessment is important but will not reduce the patient's risk for infection during tracheostomy care. Monitoring the patient for indications that tracheostomy care is needed will not reduce the patient's risk for infection. Although the NAP would be instructed to report changes in tracheal drainage, such notification will not minimize the patient's risk for infection.

4. 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. Rationale: Examining each naris for patency and signs of skin breakdown will help the nurse determine which naris will accommodate a nasogastric tube with less discomfort. Although the high-Fowler's position is recommended for insertion of a nasogastric tube, the position itself will not reduce discomfort. Anesthetizing the throat would hinder the patient's ability to swallow safely during insertion of the nasogastric tube. Sipping water will not reduce the patient's discomfort.

3. 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. Rationale: Neither the patient's broken femur nor the patient's alcohol consumption would contraindicate placement of a nasogastric tube. A 73-year-old patient on anticoagulation therapy would be at high risk for bleeding, which is a contraindication for tube feeding. A 54-year-old patient with facial trauma is a contraindication for a nasogastric tube. A 67-year-old patient with unexplained nosebleeds would contraindicate placement of a nasogastric tube.

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 high-Foler's position Rationale: Positioning the patient is within NAP scope of practice. NAP are not permitted to assess bowel sounds. It is not within NAP scope of practice to determine any portion of the patient's medical history. Patient education may not be delegated to NAP.

3. Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B. Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning

B. Cleaning and assessing the skin around the stoma Rationale: Frequently cleaning and assessing the skin in the tracheostomy area will reduce the patient's risk for skin breakdown. Hydrogen peroxide is not used to cleanse the stoma and could injure the patient's skin. Assessing for signs of infection and reporting skin breakdown will not reduce the patient's risk for injury. Re-oxygenating after suctioning will not reduce the patient's risk for skin breakdown.

5. Which technique would the nurse use to change a patient's tracheostomy ties? A. Use a slipknot. B. Ensure that two fingers fit snugly under the tie. C. Knot the ends of the tie in the eyelets on the faceplate. D. Ask the patient to hold his or her breath while the ties are changed.

B. Ensure that two fingers fit snugly under the tie. Rationale: When the tie is secure, two fingers should fit snugly under it. A slipknot could become untied. Use a square knot on tracheostomy ties. The ends of the ties are not knotted at the eyelets on the faceplate. Doing so would make it difficult to change the ties when they become soiled. The patient is not asked to hold his or her breath during tracheostomy care.

2. Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing

B. Keeping an obturator and a tracheostomy tube at the patient's bedside Rationale: Keeping an obturator and a tracheostomy tube of the correct size at the patient's bedside is the best way to plan for an emergency involving a tracheostomy, such as tube dislodgement. Having a spare oxygen mask at the bedside does not constitute adequate emergency planning for a patient with a tracheostomy. Reviewing the agency's policy is important, but does not by itself constitute effective emergency planning for a patient with a tracheostomy. Instructing the family to call for help if the patient has difficulty breathing is appropriate, but does not by itself constitute effective emergency planning for a patient with a tracheostomy.

2. 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 Rationale: Of the options suggested here, water is the most effective agent for preventing tube clogging. Coffee, tea, and apple juice increase the likelihood of tube clogging. Purified water (sterile for irrigation) or saline is preferred for use as a diluent or flush solution over other fluids (including tap water).

2. 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 Rationale: If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance. Coughing will not help remove the source of resistance; rather, it is an indication that the tube is misplaced. If the tube meets resistance, neither swallowing nor hyperextending the neck will help to advance it.

3. 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." Rationale: Responsibility for this aspect of care related to NG tube management may be delegated to NAP. Responsibility for aspirating 5 mL to 10 mL of stomach contents before flushing the tube and checking to see if the NG tubing has advanced are not aspects of NG tube management that can be delegated to NAP. NAP would not be aware of what an NG-type complaint is.

5. 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 Rationale: Normal gastric pH is 5 or less. A pH greater than 7 could mean that the tube is in the small intestine or lung. The nurse must act on this finding and anticipate a chest x-ray. Doing nothing, advancing or pulling back the tube is not correct.

4. 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. Rationale: The nurse must check NG tube placement before providing a scheduled tube feeding. Listening to bowel or lung sounds would not give the nurse any information about NG tube position. Turning the patient onto his or her left side would not give the nurse any information about NG tube position.

4. Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? A. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago B. Removing the outer cannula and placing the obturator C. Holding the tracheostomy tube while the nurse changes the neck ties D. Monitoring oxygen saturation levels and placing oxygen if needed

C. Holding the tracheostomy tube while the nurse changes the neck ties Rationale: NAP may hold the tube while the nurse changes the ties during tracheostomy care. If agency policy allows it, the NAP may perform tracheostomy care only for a patient with an established tracheostomy. Removing the outer cannula would mean that the entire tracheostomy would come out. Placing an obturator is not within the NAP's scope of practice. NAP may take a pulse oximetry reading but may not monitor changes or administer oxygen.

1. 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. Rationale: Coffee-grounds aspirate indicates bleeding. The health care provider should be notified.

1. 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 Rationale: The nurse would notify the physician because he or she will need to attempt to insert the tube or determine another treatment option. Attempting to insert a tube again may harm the patient. Although documentation is necessary, it does not address the patient's need for a nasogastric tube. Delaying an attempt at inserting the nasogastric tube makes success no more likely and risks harming the patient.