NCLEX book CHAPTER 20- Care of a Client with a Tube

The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply. 1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 4. Remove the tube and place it in the other nostril. 5. Test the stomach contents for a pH indicating acidity.

1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 5. Test the stomach contents for a pH indicating acidity.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding and reinstill the residual amount. 2. Reinstill the amount and continue with administering the feeding. 3. Elevate the client's head at least 45 degrees and administer the feeding. 4. Discard the residual amount and proceed with administering the feeding.

1. Hold the feeding and reinstill the residual amount.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles on the right

1. Stridor

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak, because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Clamp the chest tube and notify the health care provider immediately.

2. Check for an air leak, because the bubbling should be intermittent.

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the health care provider to reinsert the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection.

2. Grasp the retention sutures to spread the opening.

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 action should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in a bottle of sterile water. 3. Replace the chest tube system immediately. 4. Place a sterile dressing over the disconnection site.

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

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? 1. Position the client supine to assist in medication absorption. 2. Aspirate the nasogastric tube after medication administration to maintain patency. 3. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. 4. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

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

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

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? 1. Mark the tube at 10 inches (25.5 cm). 2. Mark the tube at 32 inches (81 cm). 3. 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. 4. 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.

3. 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 assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time? 1. Retest the pH using another strip. 2. Document that the nasogastric tube is in the correct place. 3. Check for placement by auscultating for air injected into the tube. 4. Call the health care provider to request a prescription for a chest radiograph.

4. Call the health care provider to request a prescription for a chest radiograph.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Stay very still. 2. Exhale very quickly. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

4. Perform the Valsalva maneuver.

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 action? 1. Insert the tube quickly. 2. Notify the health care provider immediately. 3. Remove the tube and reinsert it when the respiratory distress subsides. 4. Pull back on the tube and wait until the respiratory distress subsides.

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