Exam 3 Lab Skill Quizzes

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. -Provide for client privacy. -Assemble bedside equipment. -Clean around the insertion site.

-Administer pain medication. Rationale: Gastrostomy feeding tubes are uncomfortable for the first days after insertion. The client will tolerate site care better after analgesic administration. While waiting for the medication to take effect, the nurse can prepare the area. After the medication is working, the nurse provides for privacy and begins site care, carefully assessing for other reasons for site pain including excessive erythema or edema.

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 should the nurse take next? -Apply a skin barrier to the insertion site. -Apply gentle pressure to the tube while pressing the external bumper closer to the skin. -Notify the health care provider. -Gently rotate the external bumper 90 degrees.

-Apply gentle pressure to the tube while pressing the external bumper closer to the skin. Rationale: If there is a large amount of slack between the internal guard and the external bumper, drainage can leak out of the site. In this case, the nurse should apply gentle pressure to tube while pressing the external bumper closer to the skin. Although the nurse should gently rotate the external bumper 90 degrees at least once a day, this action would not address the leaking of the tube. Skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address the leaking, either. There is no need to notify the health care provider regarding this issue.

The nurse is caring for a client who had a percutaneous endoscopic gastrostomy tube inserted earlier in the day. The sutures are still in place. Which interventions should the nurse plan to perform? Select all that apply. -Gently rotate the external bumper 90 degrees once during the shift. -Avoid placing tension on the feeding tube. -Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. -Place a dressing between the skin and external bumper. -Administer prescribed analgesics, as needed. -Measure the length of exposed tube and compare it with the length documented after insertion.

-Avoid placing tension on the feeding tube. , -Gently clean around the insertion site using a cotton-tipped applicator dipped in sterile saline. -Administer prescribed analgesics, as needed. -Measure the length of exposed tube and compare it with the length documented after insertion. Rationale: Feeding tubes can be uncomfortable, especially the first few days after insertion. Analgesic medication may permit the client to tolerate the insertion site care more easily. Cleansing the new site with sterile saline solution helps prevent infection. Measuring the tube assures that the tube has not migrated. Avoiding placing tension on the tube helps prevent skin breakdown. Rotating the external bumper 90 degrees should be done after sutures have been removed. A dressing should be used only if drainage is present; otherwise, it should be left open to the air.

The nurse is caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action would be most appropriate to address this concern? -Apply a skin barrier to the insertion site. -Notify the health care provider for a prescription to apply an antifungal powder. -Administer an antibiotic as prescribed. -Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

-Notify the health care provider for a prescription to apply an antifungal powder. Rationale: If the skin has a patchy, red rash, the cause could be candidiasis (yeast). The nurse should notify the health care provider for a prescription to apply an antifungal powder. Applying gentle pressure to the tube while pressing the external bumper closer to the skin is performed when there is slack between the external bumper and the internal guard, resulting in leaking from the tube. An antibiotic would not be indicated for treating candidiasis. A skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address candidiasis, either.

A nurse is irrigating a client's nasogastric tube. Place the following steps in the correct order. Use all options.

1)Check placement of the nasogastric tube. 2)Draw up 30 mL of irrigation solution into a syringe. 3)Clamp the nasogastric tube near the connection site. 4)Hold the syringe upright, and gently insert the irrigant. 5)Hold the end of the nasogastric tube over an emesis basin. 6)Inject air into the blue air vent. Rationale: Checking placement before the instillation of fluid is necessary to prevent accidental instillation into the respiratory tract if the tube has become dislodged. Drawing up the specified amount of solution into a syringe ensures delivery of the proper amount of irrigant through the tube. Clamping prevents leakage of gastric fluid. Gentle insertion of saline solution (or gravity insertion) is less traumatic to gastric mucosa. Return flow may be collected in an irrigating tray or other available container and measured. This amount needs to be subtracted from the irrigant to record the true nasogastric drainage. Following irrigation, the blue air vent is injected with air to keep it clear.

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 45̊ 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. Rationale: Elevating the head of the bed 30 to 45̊ degrees minimizes the possibility of aspiration into the trachea. Verifying correct tube placement ensures that the formula is being delivered to the stomach appropriately. The nurse should aspirate all gastric contents with the syringe and measure to check for gastric residual, the amount of feeding remaining in the stomach from the previous feeding. This is done to identify delayed gastric emptying. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia, so feedings should be held if residual volumes exceed 200 mL on two successive assessments. Flushing the tube prevents occlusion.

A client scheduled for the removal of a nasogastric tube asks the nurse, "Will taking out the tube hurt?" What is the nurse's best response? -"We will numb your throat prior to removal so you will not experience any pain." -"Don't worry, I've done this procedure many times and no one has complained of pain." -"You may experience minor discomfort as the tube is being removed." -"We will give you pain medication since tube removal causes moderate pain."

"You may experience minor discomfort as the tube is being removed." Rationale: The nurse would explain to the client that minor discomfort may be experienced for a few seconds but that the nose and throat will feel better once the tube is out. The procedure does not require pain medication or anesthetics.

The nurse performs gastrostomy site care and notes drainage. What action does the nurse take? -Notify the health care provider. -Clean the site with hydrogen peroxide. -Administer an antibiotic ointment to the site. -Place a drain sponge under the external bumper.

-Place a drain sponge under the external bumper. Rationale: When the nurse notes drainage, a precut sponge or gauze is placed around the tube for comfort and to prevent irritation. Drainage is a normal finding. The health care provider is notified if the drainage has an odor, appears infected, or looks like the feeding solution being administered. Gastrostomy sites are no longer cleansed with hydrogen peroxide as this disrupts healing. Antibiotic ointments have not been found to be useful and are not used.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. At what level should the nurse place the feeding bag on the pole? -12 in (30 cm) below the stomach. -12 in (30 cm) above the stomach. -At stomach level. -24 in (60 cm) above the stomach.

12 in (30 cm) above the stomach. Rationale: The nurse would hang the feeding bag 12 in (30 cm) above the stomach. Proper feeding bag height reduces the risk of formula being introduced too quickly.

The nurse has finished aspirating the gastric contents before administering a prefilled, continuous tube feeding. At this point in the procedure, how much sterile water would the nurse use to flush the tube? -40 mL -10 mL -20 mL -30 mL

30 mL Rationale: Following aspiration of the gastric contents, the nurse would use 30 mL of sterile water to flush the tube. Water rinses the feeding from the tube and keeps it patent.

A client is receiving a continuous tube feeding. Which accurately describes an aspect of this procedure? -The procedure for inserting the tube is different from that for an intermittent feeding. -The continuous feeding is administered over a 12-hour period. -The nurse should check for residual every 8 hours. -A feeding pump is used for a continuous feeding.

A feeding pump is used for a continuous feeding. Rationale: A continuous tube feeding is administered over a 24-hour period and a feeding pump is always used. The nurse would check for residual every four to six hours. Regardless of the type of tube used, the procedure for tube insertion is the same.

The nurse provides the client with a gravity feeding via a gastrostomy tube. Which action is correct? -Assist the client to obtain a desired and comfortable position. -Flush the gastrostomy tube with 60 mL of sterile water. -Remove and waste gastric residual contents. -Allow the feeding to infuse slowly from the feeding bag.

Allow the feeding to infuse slowly from the feeding bag. Rationale: The nurse allows the gravity feeding to infuse over about 30 minutes from the feeding bag. The tube is flushed before and after feedings with 30 mL of tap water. Gastric contents are replaced unless there is a large quantity according to institution policy. The nurse does assist the client to be comfortable, but the client must stay in an upright position for approximately 1 hour after feeding for safety.

The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next? -Secure the tube to the client's nose using tape. -Apply skin barrier to the tip and end of the nose. -Measure the length of the exposed tube. -Lubricate the lips generously.

Apply skin barrier to the tip and end of the nose. Rationale: Skin barrier improves adhesion and protects the skin. Applying the skin barrier should occur before taping the tube to the client's nose, measuring the length of exposed tube, or lubricating the lips.

Which would be most appropriate for the nurse to do when removing a nasogastric (NG) tube? -Ask the client to take a deep breath and pull out the tube slowly and carefully. -Ask the client to take a deep breath and pull out the tube quickly and carefully. -Ask the client to take short shallow breaths and pull out the tube slowly and carefully. -Ask the client to turn the head to the side with the chin tilted up when pulling out tube.

Ask the client to take a deep breath and pull out the tube quickly and carefully. Rationale: When pulling out an NG tube, the nurse should ask the client to take a deep breath on the count of three and pull it out quickly and carefully. The client holds his or her breath to prevent accidental aspiration of gastric secretions in the tube. Careful removal minimizes trauma and discomfort for the client.

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first? -Check gastric residual. -Pour a premeasured amount of tube feeding formula into the nasogastric tube. -Aspirate stomach contents and check pH. -Flush the nasogastric tube with the ordered amount of water.

Aspirate stomach contents and check pH. Rationale: Nasogastric tube placement should be checked before flushing, giving medications, or feeding. After placement has been ensured, the gastric residual should be checked, the nasogastric tube should be flushed as ordered, and the tube feeding administered.

A client has had a nasogastric tube inserted in preparation for tube feedings. When developing the client's plan of care, the nurse would anticipate checking the placement of the tube at which time? -At the beginning of each shift -Every 8 hours during a continuous tube feeding -After administering an intermittent tube feeding -Before administering a medication through the tube

Before administering a medication through the tube Rationale: The nurse would verify correct placement of the nasogastric tube after the initial insertion, before beginning a feeding or instilling medications or liquids, and at 4-hour intervals during continuous feedings. This ensures that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place. A misplaced feeding tube in the lungs or pulmonary tissue places the client at risk for aspiration.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. After checking tube placement, which action would the nurse take next? -Open the roller clamp and run the formula through tubing to purge the air. -Flush the tube with sterile water for irrigation. -Check the residual (the amount of feeding left in the stomach from the last feeding). -Attach the feeding set-up to the feeding tube.

Check the residual (the amount of feeding left in the stomach from the last feeding). Rationale: After checking for tube placement, the nurse would check for the residual and then flush the tube with 30 mL of sterile water. If the residual amount does not exceed agency policy or the limit indicated in the medical record, then the nurse would proceed with the feeding.

When administering a continuous tube feeding using a feeding pump and closed tube feeding system, the nurse plans to check for residual at which frequency? -Every 6 to 8 hours. -Every 2 to 4 hours. -Every 1 to 2 hours. -Every 4 to 6 hours.

Every 4 to 6 hours. Rationale: When administering a continuous tube feeding, the nurse would check for residual every 4 to 6 hours.

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube? Every 8 to 10 hours Every 4 to 8 hours Every 1 to 2 hours Nasogastric tubes should not be irrigated.

Every 4 to 8 hours Rationale: The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.

The health care provider has written a prescription for a client's nasogastric (NG) tube to be removed. Which would the nurse do first? -Remove the tube from the client gown. -Discontinue the suction. -Separate the NG tube from the suction tubing. -Take off the adhesive tape from the client's nose.

Discontinue the suction. Rationale: The prescription in which the nurse performs the above steps for removing an NG tube are as follows: discontinue the suction, remove the tube from the client gown, take off the adhesive tape from client's nose, and separate the NG tube from the suction tubing.

The nurse is administering an intermittent tube feeding to a client via gravity using an open feeding bag system. What step would the nurse perform when the feeding bag is empty? -Remove the bag and tubing and discard. -Flush the feeding bag with 30 mL water. -Aspirate the gastric contents. -Assess the abdomen for bowel sounds.

Flush the feeding bag with 30 mL water. Rationale: When the feeding bag is empty, the nurse would flush the feeding bag with 30 mL water to flush out the bag itself and the feeding tube at the same time. The nurse would then clamp the tubing when the water is instilled.

A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client? -One nare being less patent than the other -History of facial fractures -Bleeding in the gastrointestinal tract -Abdominal distention

History of facial fractures Rationale: Clients with facial fractures or facial surgeries present a higher risk for misplacement of the tube into the brain. Many institutions require a health care provider to place NG tubes in these clients, which would contraindicate the nurse placing the tube. The nurse should assess the patency of the client's nares by asking the client to occlude one nostril and breathe normally through the other. However, the nurse does this to select the nostril through which air passes more easily, not because one nare being less patent than the other is a contraindication for NG tube placement by the nurse. Abdominal distention does not contraindicate NG tube placement. Monitoring bleeding in the gastrointestinal (GI) tract is one of the indications for NG tube placement, so bleeding in the GI tract is not a contraindication.

In what position would the nurse place the client prior to removing a nasogastric tube? -Flat with the side rails up. -In a flat position with the bedrail nearest the nurse down. -Sitting on the side of the bed. -In an upright position with the bedrail nearest the nurse down.

In an upright position with the bedrail nearest the nurse down. Rationale: The nurse would place the client in an upright position in bed with the rail nearest the nurse down. Appropriate client positioning facilitates comfort for the client and the nurse, ensuring proper body mechanics for the nurse.

When irrigating a nasogastric tube, the nurse does not get a return after instilling the irrigation solution and reconnecting the tube back to the suction unit. What would be the nurse's next step in this situation? -Instill 30 mL of irrigation solution into the tube and aspirate again. -Instill 20 mL of air into the tube and aspirate again. -Check the placement of the tube and repeat the procedure. -Instill 20 mL of water into the tube and aspirate again.

Instill 20 mL of air into the tube and aspirate again. Rationale: If the nurse does not get a return after instilling the irrigation solution and reconnecting the tube back to the suction unit, he or she should instill 10 to 20 mL of air into the tube to clear it and aspirate again.

The nurse is monitoring a client who had a nasogastric (NG) tube placed postoperatively after abdominal surgery. Which criterion would the nurse use to determine that the tube could be removed? -Absent bowel sounds. -Passage of flatus. -Stable vital signs. -Loss of appetite.

Passage of flatus. Rationale: The criteria used to determine that an NG tube can be removed are: return of appetite, return of bowel sounds, and passage of flatus. All of these signs represent a return to normalcy of the gastrointestinal system. Stable vital signs are preferable, but this is not one of the major criteria for tube removal.

The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what does the nurse do next? -Notify the health care provider. -Proceed with nasogastric tube placement. -Assess the client's respiratory status. -Insert the tube into the other nostril.

Proceed with nasogastric tube placement. Rationale: The nurse first ensures that any coughing is related to the gag reflex rather than accidental placement of the NG tube into the airway. When the client breathes and speaks adequately, placement may continue. The nurse has performed the necessary respiratory assessment by ensuring the client can speak well. There is no reason to begin again with the other nostril or to notify the health care provider.

The nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method should the nurse use to increase the flow rate of the formula? -Ask the client to bear down while the formula is infusing. -Attach the syringe to a syringe pump and set the infusion rate to 250 mL/hr. -Using the plunger of the syringe, steadily infuse the formula over the desired period of time. -Raise the height of the syringe.

Raise the height of the syringe. Rationale: Syringe feedings are infused via gravity. Raising the syringe will increase the rate of infusion. Syringe pumps are used for IV infusions rather than gastric feeding. Feeding through a syringe should be done by gravity, not by positive pressure using the plunger. The client bearing down will likely have little effect on the rate of infusion.

The nurse is irrigating a nasogastric (NG) tube connected to suction for a client undergoing gastric decompression and meets resistance after attaching the irrigation syringe to the NG tube. Which would be most appropriate for the nurse to do first? Use 50 mL air instead of irrigation solution. Reposition the client and try again. Notify the health care provider. Use 20 mL sterile saline instead of irrigation solution.

Reposition the client and try again. Rationale: The nurse who meets resistance when irrigating a nasogastric tube connected to suction should reposition the client first and try again because sometimes the tube can get pushed up against the stomach wall. Repositioning the client can help to remedy this situation. If repositioning fails, the nurse can use 20 mL air instead of irrigation solution to reposition the end of the tube.

Following insertion of a nasogastric 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. -Allow the tubing to hang freely to allow for freedom of movement. -Attach the tubing to the bed linens with a rubber band and safety pin. -Tape the tubing to the client's sleeve below shoulder level.

Secure the tubing with a safety pin to the client's gown at shoulder level. Rationale: The nurse would secure the tube to the client's gown at the sleeve by using a safety pin, and perhaps a rubber band, ensuring that the air vent is above the level of the stomach. Securing the tube prevents tension and tugging on the tube. Securing the tube in any other place and in any other manner or failure to secure the tube at all can allow the tube to be accidentally removed, possibly requiring reinsertion.

A nurse aspirates a small amount of fluid from a client's nasogastric tube. The nurse determines that the tube is in the intestines based on the aspirate being which color? -Tan -Straw-colored -Green -Off-white

Straw-colored Rationale: Gastric fluid can be green with particles, off-white, or brown if old blood is present. Intestinal aspirate tends to look clear or straw-colored to a deep golden yellow color. Also, intestinal aspirate may be greenish brown if stained with bile. Respiratory or tracheobronchial fluid is usually off-white to tan and may be tinged with mucus.

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 client is forcefully resisting the procedure. -The NG tube is curled in the back of the client's throat. -The client is experiencing a vasovagal reaction. -The NG tube is in the client's airway.

The NG tube is in the client's airway. Rationale: The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.

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 would require intervention by the charge nurse? -The new nurse asks the client whether nausea or abdominal pain is present. -The new nurse interrupts the feeding every 4 hours and aspirates gastric contents. -The new nurse changes gloves before preparing the feeding bag. -The new nurse places the client in the left lateral recumbent position.

The new nurse places the client in the left lateral recumbent position. Rationale: The client's head should be elevated 30 to 45 degrees. All of the other actions are correct and would not require intervention by the charge nurse.

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube? -Radiographic confirmation of position -Confirmation that pH of the aspirate is less than 5.5 -Off-white fluid aspirated -Green fluid with particles aspirated

-Radiographic confirmation of position Rationale: Radiographic (x-ray) examination is the only reliable method to determine accurate tube placement. In the absence of an x-ray, pH testing is predicative of correct placement. Although visualization of aspirated contents can help confirm correct placement of the tube, this method is not as reliable as an x-ray.

Which documentation does the nurse complete after inserting a client's nasogastric (NG) tube?

-measurement of the exposed tube Rationale: The nurse would document the size and type of NG tube that was inserted, the nare used for insertion, the measurement of the exposed tube, the characteristics of the drainage in the tube, and the client's reaction to the procedure. It is not relevant to know how long the NG insertion took or how difficult it was, unless there was trauma. Placing an NG tube is procedure that is not expected to alter the client's vital signs, and it will not immediately alter the client's bowel sounds.

When irrigating a nasogastric (NG) tube, how many mL of irrigating solution would the nurse usually instill into the tube unless another amount is prescribed? 20 mL 25 mL 15 mL 30 mL

30 mL Rationale: Normally the nurse would instill 30 mL of irrigating solution or the specific amount prescribed into the NG tube. Irrigation clears the tube of any debris or formula and helps to keep it patent.

The nurse is providing a continuous tube feeding for a client. At what angle should the head of the bed be set during the feeding? -90 degrees. -30 to 45 degrees. -20 to 25 degrees. -15 to 20 degrees.

30 to 45 degrees. Rationale: During the administration of a continuous tube feeding, the head of the bed should be elevated at 30 to 45 degrees. This position minimizes possibility of aspiration into the trachea. Clients considered high risk for aspiration should be assisted to at least a 45-degree position.

In what position would the nurse hold the syringe when instilling irrigation solution into the nasogastric (NG) tube?

Downward at a 90-degree angle. Rationale: After drawing up the irrigation in the syringe, the nurse would hold the syringe upright (90-degree angle) and downward. This allows for a natural flow of the irrigation solution into the NG tube.

A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption? -Serum albumin 2.8 g/dL (28 g/L) -Creatinine 1.9 mg/dL (168 μmol/L) -Hemoglobin (Hgb) 11.3 g/dL (113 g/L) -Hematocrit (Hct) 56% (0.56)

Serum albumin 2.8 g/dL (28 g/L) Rationale: Normal serum albumin is 3.3 to 5 g/dL (33 to 50 g/L). Decreased albumin indicates malnutrition or malabsorption. Decreased Hgb indicates anemia. Increased creatinine indicates dehydration. Increased Hct indicates dehydration.

Which should the nurse advise the client to do following successful administration of a tube feeding? -Lay flat for 30 to 60 minutes. -Sit up for 1 hour. -Ambulate for 20 minutes if not contraindicated. -Sit up for 1.5 to 2 hours.

Sit up for 1 hour. Rationale: After administering a tube feeding, the nurse should have the client sit up for at least 30 minutes to one hour to minimize risk for backflow or aspiration if any reflux or vomiting should occur.

The nurse irrigates a client's nasogastric tube with 20 mL of air. The nurse assesses for which outcome? auscultating normal bowel sounds obtaining gastric secretion residual flushing the nasogastric tube easily reducing the intensity of nausea

flushing the nasogastric tube easily Rationale: When the nurse irrigates the nasogastric tube with air, the primary anticipated outcome is to be able to flush the tube easily. The client with a nasogastric tube is not expected to have normoactive bowel sounds. The nurse may obtain gastric secretions for pH, but this is not the goal of irrigating the tube. Irrigation does not reduce nausea, although placing the tube to suction should reduce nausea.

The nurse is following the protocol for irrigating a client's nasogastric (NG) tube. Before attaching the syringe to irrigate the tube, which action would be most important for the nurse to do? Check tube placement. Clamp the tube. Have the client lie flat. Clear the air vent.

Check tube placement. Rationale: The nurse needs to check tube placement before instilling any solution into the NG tube to prevent possible aspiration. The tube is clamped intermittently throughout the procedure to prevent air from entering the system. However, if the tube was clamped for irrigating, the tube could not be irrigated. There is no need to clear the air vent. The client should be in an upright position to discourage aspiration if any reflux or vomiting should occur.

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 is correct? -Mix meat tenderizer with 30 mL of warm water, instill the mixture into the feeding tube, wait 15 minutes, and then flush vigorously. -Insert a stylet until resistance is felt, and then gently rotate the stylet until resistance decreases. -Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. -Advance the tube no more than 4 in (10 cm), auscultate for bowel sounds, and then attempt to aspirate again.

Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. Rationale: Most obstructions are caused by coagulation of formula. The nurse should try using warm water and gentle pressure to remove the clog. Carbonated sodas, such as Coca-Cola, and meat tenderizers have not been shown effective in removing clogs in feeding tubes. Never use a stylet to unclog tubes. Advancing the tube is not needed, as this will not address the clog.

When monitoring a client with a continuous tube feeding, how often should the nurse confirm placement of the tube? -Every 2 to 4 hours. -Every shift. -Every 24 hours. -Every 4 to 6 hours.

Every 4 to 6 hours. Rationale: The nurse would confirm the tube placement for a client receiving a continuous tube feeding every 4 to 6 hours. Checking placement verifies that the tube has not moved out of the stomach.

The nurse meets resistance when irrigating a nasogastric tube. What action does the nurse take? Flush with a small amount of air. Attach the tubing to suction. Attempt to irrigate more forcefully. Instruct the client to cough deeply.

Flush with a small amount of air. Rationale: Flushing the tube with air will push the end of the tube away from the gastric wall, enabling flushing. Attaching the tubing to suction will not help this client. It is never wise to flush any tubing after meeting resistance; troubleshooting the tubing or catheter is done when resistance is met. Though coughing increases intrathoracic pressure, it will not likely dislodge the nasogastric tube to allow for irrigation and proper suction, if needed.

Following the removal of a nasogastric NG tube, the nurse should monitor the client for which possible adverse reaction? -Fluid and electrolyte imbalance. -Decreased fluid output. -Elevated blood pressure. -Gastric distention.

Gastric distention. Rationale: Following the removal of an NG tube, the nurse would monitor for gastric distention and nausea and vomiting. If the client's abdomen is showing signs of distention, the nurse should notify the health care provider who may prescribe the nurse to replace the NG tube.

When a nurse meets resistance while irrigating a nasogastric tube, the nurse should assess the client for which sign/symptom? Respiratory rate. Vital signs. Gastric fullness. Cyanosis.

Gastric fullness. Rationale: Following resistance upon tube irrigation, the nurse would assess the client for nausea, vomiting, gastric fullness, and stomach distention. If the client is showing these signs, the health care provider should be notified.

The nurse is preparing to irrigate the client's nasogastric (NG) tube. Which statement accurately describes the proper method of injecting irrigation solution into an NG tube? Inject the solution slowly with gentle force. Inject the solution intermittently at three-minute intervals. Inject the solution quickly and forcefully. Inject half the solution, wait five minutes and inject the other half.

Inject the solution slowly with gentle force. Rationale: When irrigating a nasogastric tube, the nurse should inject the solution slowly with gentle force, unless policy dictates that a gravity flow be used. Slowly injected solution clears the tube of secretions, feeding, or debris.

The nurse, removing a nasogastric (NG) tube from a client, flushes the NG tube prior to removing it. Which would be most appropriate for the nurse to do? -Instill 15 to 30 mL of air to clear the tube. -Flush the tube with 50 to 75 mL sterile water. -Flush the tube with irrigation solution. -Instill 30 to 50 mL of air to clear the tube.

Instill 30 to 50 mL of air to clear the tube. Rationale: When flushing the NG tube prior to removal, the nurse would either flush the tube with 10 mL of water or normal saline solution or instill 30 to 50 mL of air to clear the tube. The nurse would also check the facility's policy.

The nurse is not successful in attempting to irrigate a nasogastric tube. The nurse repositions the client and tries to flush the tube with air and water multiple times without success. What action does the nurse take next? Notify the health care provider. Replace the nasogastric tube. Remove the nasogastric tube. Document implemented interventions.

Notify the health care provider. Rationale: If the nasogastric tube is not working properly after correct nursing interventions are attempted, the health care provider is notified to discuss possible complications and further interventions. The nurse may end up removing and replacing the nasogastric tube, but this is not the next action. Documentation occurs after notifying the provider and includes all actions and outcomes of those actions.

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? -to the abdominal umbilicus -to the mammary line -to the tenth intercostal space -to the xiphoid process

to the xiphoid process Rationale: The nurse measures the distance to insert the NG tube by placing the tip of the tube at client's nostril and extending to the tip of the ear lobe and then to the tip of the xiphoid process. This measurement ensures that the tube will be long enough to enter the client's stomach without needless coiling. Measuring to the mammary line is too short by about 1 in (2.5 cm) and to the tenth intercostal space or the umbilicus is too long.

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? -sterile water -water-soluble lubricant -normal saline solution -petroleum jelly

water-soluble lubricant Rationale: The nurse would lubricate the tip of the tube with water-soluble lubricant. Lubrication reduces friction and facilitates passage of the tube into the stomach. Water-soluble lubricant will not cause pneumonia if the tube accidentally enters the lungs. Saline and water are not considered lubricants. Jelly-based lubricants can be dangerous, particularly if aspirated.

The nurse has completed irrigation of a nasogastric tube connected to suction. Which step would the nurse perform following the injection of irrigation solution into a client's nasogastric tube? Connect the unclamped NG tube back to the suction unit. Aspirate half the used amount of irrigation solution back into the syringe. Check the placement of the tube by aspirating gastric contents. Inject 30 mL of sterile water into the tube.

Connect the unclamped NG tube back to the suction unit. Rationale: Following the administration of the irrigation solution into a client's NG tube, the nurse would either connect the NG tube back to the suction unit and unclamp it to withdraw fluid, or aspirate an equal amount of fluid back into the syringe. Alternatively, the nurse can hold the end of the NG tube over an irrigation tray or emesis basin and observe for the return flow of NG drainage.

After inserting a nasogastric tube, what should the nurse do to ensure that the tube is properly placed in the client? -Observe for immediate drainage from the tube. -Ask about stomach distention and fullness. -Obtain an abdominal ultrasound. -Test the pH of aspirated content.

Test the pH of aspirated content. Rationale: Current research demonstrates that the use of pH is predictive of correct placement of a nasogastric tube. The pH of gastric contents is acidic (less than 5.5). If the client is taking an acid-inhibiting agent, the range may be 4.0 to 6.0. The pH of intestinal fluid is 7.0 or higher, indicating the tube is beyond the stomach. The pH of respiratory fluid is 6.0 or higher. An x-ray can also be used to check placement of the tube, as well as aspirating the gastric contents and checking them for color and consistency. A feeling of fullness will not confirm tube placement. An ultrasound is not used for confirmation of tube placement.

The nurse has difficulty irrigating a nasogastric tube. The nursing interventions are successful, and the nurse irrigates the tube. Which finding indicates to the nurse that the client tolerated the procedure well? vomiting gastric gurgling abdominal distention nausea

gastric gurgling Rationale: Gastric gurgling is a normal finding, particularly after the nurse has flushed with air and water. Abdominal distention, nausea, and vomiting are indications that the client did not tolerate the irrigating procedure and may require additional interventions such as nausea medication.

The nurse is preparing to irrigate a client's NG tube. Which would the nurse include when teaching the client about this procedure? "You may experience nausea or vomiting during the flush." "You will not experience any unusual sensations with this procedure." "You may feel cold solution going down your throat, but it should not hurt." "You may feel a slight burning sensation in the throat."

"You may feel cold solution going down your throat, but it should not hurt." Rationale: The nurse should inform the client that when the tube is flushed with solution, it may feel cold going down the throat, but it will not hurt. The procedure may be a bit uncomfortable, and a sensation of cold may be felt in the throat, but pain, nausea, and vomiting is not normally involved.

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's 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. Rationale: An upright position is more natural for swallowing and protects against bronchial intubation aspiration, if the client should vomit. Therefore, the high Fowler's position is recommended for the client. Measurement ensures that the tube will be long enough to enter the client's stomach. Lubrication reduces friction and facilitates passage of the tube into stomach. Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likelihood of mucosal injury. Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube, causes the epiglottis to cover the opening of the trachea, and helps to eliminate gagging and coughing.