FON CHP 15 Elimination & Gastric Intubation

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions would the nurse perform be- fore initiating the feeding? Select all that apply. 1. Irrigate the NG tube with saline. 2. Explain the procedure to the client. 3. Elevate the head of the bed to 45 degrees. 4. Aspirate all stomach contents and discard 5. Ensure that the end of the NG tube is in the esophagus. 6. Have a pair of scissors for emergency use at the bedside.

1. Irrigate the NG tube with saline. 2. Explain the procedure to the client. 3. Elevate the head of the bed to 45 degrees.

The nurse caring for a patient with an indwelling catheter should perform which actions to lower the risk for infection? (Select all that apply.) 1. Keep drainage bag below the level of the bed. 2. Provide perineal care twice a day 3. Coil tubing on the bed 4. Keep the drainage system closed. 5. Limit fluid intake to 300 mL per shift.

1. Keep drainage bag below the level of the bed. 2. Provide perineal care twice a day 3. Coil tubing on the bed 4. Keep the drainage system closed.

The nurse is preparing to administer an intermit. tent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions would the nurse take? Select all that apply. 1. Listen to the client's bowel sounds. 2. Document and discard the residual. 3. Offer the client sips of water to drink. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distension. 6. Hold the feeding after flushing the tubing with 30 mL saline.

1. Listen to the client's bowel sounds. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distension. 6. Hold the feeding after flushing the tubing with 30 mL saline.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the cli- ent becomes restless and tachycardic. Which actions would the nurse take? Select all that apply. 1. Notify the registered nurse (RN). 2. Notify the Rapid Response team. 3. Finish the suctioning as quickly as possible. 4. Discontinue suctioning until the client is stabilized. 5. Contact the respiratory department to suction the client.

1. Notify the registered nurse (RN). 4. Discontinue suctioning until the client is stabilized.

The nurse has assisted in inserting a nasogastric (NG) tube in a client and is checking for the correct placement of a NG tube. Which is the most reli- able data to ensure that the end of the tube is in the stomach? 1.Placement is verified on x-ray. 2. The pH of the aspirated fluid is 5. 3. The aspirated fluid is bile green in color. 4. Air injection is auscultated in the left upper quad- rant.

1.Placement is verified on x-ray.

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions would be included to accurately administer the medication? Select all that apply. 1. Position the client supine to assist with medication absorption. 2. Clamp the NG tube for 30 minutes after med- cation administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during administration of medication.

2. Clamp the NG tube for 30 minutes after medcation administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during administration of medication.

The nurse is assigned to assist with caring for a ci- ent who has a chest tube. The nurse notes fluctua- tons of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? 1. Empty the drainage. 2. Continue to monitor. 3. Encourage the client to deep breathe. 4. Encourage the client to hold his or her breath periodically.

2. Continue to monitor.

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions would the nurse antici- pate performing during this process? Select all that apply. 1. Reinforce instructions to breathe deeply while the tube is removed. 2. Cover the site with an occlusive dressing after the tube is removed. 3. Clamp the chest tube near the insertion site just before the removal. 4. Raise the drainage system to the level of the chest tube insertion site. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2. Cover the site with an occlusive dressing after the tube is removed. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

The nurse is preparing to administer an intermit- tent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What would the nurse do? Select all that apply. 1. Hold the feeding. 2. Document the amount of residual. 3. Place it into a container for laboratory analysis. 4. Reinstill the residual and administer the feeding. 5. Deduct the amount of the residual from the new feeding before administering.

2. Document the amount of residual. 4. Reinstill the residual and administer the feeding.

To maintain proper drainage of an indwelling catheter, it is important to perform which action? 1. Irrigate the catheter every 2 to 4 hours. 2. Ensure that the collection device is below bladder level 3. Place tubing under the patients leg to prevent pulling on the bladder neck 4. Demonstrate to the patient how to disconnect the device while ambulating.

2. Ensure that the collection device is below bladder level

A licensed practical nurse (LP) is preparing to assist a registered nurse (RN) with removing a na- sogastric (NG) tube from the client. Which inter- ventions would be included in the procedure? Select all that apply. 1. Remove the air from the balloon. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuous steady motion. 5. Remove the device or tape securing the tube from the nose.

2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuous steady motion. 5. Remove the device or tape securing the tube from the nose.

A bladder retraining program for a patient in an extended-care facility should include which intervention? (Select all that apply) 1. Providing negative reinforcement when the patient Is incontinent. 2. Having the patient wear clothing protectors to help decrease embarrassment. 3. Initiating a toilet schedule of every 2 hours during the day. 4. Promoting the intake of caffeine to stimulate voiding. 5. Encouraging the use of the bedpan.

2. Having the patient wear clothing protectors to help decrease embarrassment. 3. Initiating a toilet schedule of every 2 hours during the day.

1. What would the nurse do to determine the correct distance to insert a nasogastric tube? 1. Measure from center of forehead to top of nose to end of sternum. 2. Measure from tip of nose to tip of earlobe to the xiphoid process. 3. Measure from lips to tip of ear to just below the umbilicus. 4. Measure from tip of ear to midway between end of sternum and umbilicus.

2. Measure from tip of nose to tip of earlobe to the xiphoid process.

The nurse is administering a cleansing enema to an adult patient. The patient complains of cramping and the urge to defecate. Which nursing intervention is the best to carry out? 1. Quickly finish instilling the rest of the solution. 2. Slow the flow and encourage the patient to take deep breaths, 3. Instruct the patient to hold his or her breath and bear down. 4. Immediately discontinue the instillation and withdraw the enema tubing from the rectum.

2. Slow the flow and encourage the patient to take deep breaths

Bladder training instructions are being given to a patient wo has a history of urinary incontinence. The nurse should give the patient which instruction? 1. "Wait until you feel the urge to void." 2."Don't void any more often than every 4 to 6 hours. 3. "Void every 1.5 to 2 hours while you are awake " 4."Void any time you feel the urge.

3. "Void every 1.5 to 2 hours while you are awake "

A patient is transferred from the postanesthesia care unit (PACU) to the postoperative unit following abdominal stumper, for placement of a transverse colostomy: The patient has a" nasogastric tube to medium intermittent-suction. What actions can the nurse perform to verify correct placement of the nasogastric tube? (Select all that apply.) 1. Assess the patient for complaints of abdominal pain o nausea. 2. The nurse injects 30 mL of normal saline through the nasogastric tube with ease. 3. The nurse auscultates a gurgling or a swishing sound heard with a stethoscope over the stomach when ais injected into the tube 4. The nurse aspirates gastric contents with the a syringe. appearance of being a watery yellow or green tint with 5. The nurse places the end of the tube in a glass of water and watches for bubbling. 6. The nurse contacts the x-ray department to perform an ×-ray for placement verification according to provider's orders. 7. The nurse aspirates contents from the nasogastric tube and checks the pH to determine if the pH below 4. 8. The nurse asks the patient if they can feel suction in their stomach when initiating the suction. 9. The nurse assesses the amount of drainage in the nasogastric tube to determine if it is in the stomach.

3. The nurse auscultates a gurgling or a swishing sound heard with a stethoscope over the stomach when ais injected into the tube 4. The nurse aspirates gastric contents with the a syringe.

Ostomy

An ostomy pouching system is a prosthetic medical device that provides a means for the collection of waste from a surgically diverted biological system and the creation of a stoma.

A patient has a nasogastric tube inserted. What type of patient teaching should the nurse give the patient about the nasogastric tube? (Select all that apply.) 1. "Be careful to not pull on the tube." 2. "Call the nurse if you feel as if you are going to vomit." 3. "Turn the suction off if you feel as if you are going to vomit." 4. "Refrain from coughing while the tube is in place. 5. "Let the staff know if the tape holding the tube is irritating your skin."

1. "Be careful to not pull on the tube." 2. "Call the nurse if you feel as if you are going to vomit." 5. "Let the staff know if the tape holding the tube is irritating your skin."

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1. Enables the client to speak 2. Is necessary for mechanical ventilation 3. Must have the cuff deflated when capped 4. Eliminates the need for tracheostomy care 5. Prevents air from being inhaled through the tracheostomy opening

1. Enables the client to speak 3. Must have the cuff deflated when capped

The nurse is assisting in planning care for a client with a chest tube. The nurse would suggest to in- clude which interventions in the plan? Select all that apply. 1. Pin the tubing to the bed linens. 2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or Obstructed. 5. Empty the drainage from the drainage collection chamber daily.

2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or Obstructed.

A male patient with urinary incontinence has been using an external condom) catheter the nurse is evaluating the patients technique of applying the device. Which finding would indicate that the nurse should give the patient further instructions? select all that apply. 1.Washing the penis with warm, soapy water and crying the area well before applying the device 2. Using tape around the penis to secure the device 3. using a narrow width elastic bandage to wrap in a spiral pattern to secure the device 4. Checking the penis carefully for any signs of irritation before applying the device 5.Changing the catheter after each episode of urinary incontinence 6. Applying a leg bag to the condom catheter during the day and changing to a larger drainage bag at night 7. Removing the condom catheter at night and using an incontinent pad for urine incontinence 8. Using a foam skin applicator that has adhesive on the outside to hold the condom catheter in place

2. Using tape around the penis to secure the device 3. using a narrow width elastic bandage to wrap in a spiral pattern to secure the device 5.Changing the catheter after each episode of urinary incontinence

A patient with a colostomy continues to worry about odor. Which statement would be appropriate for the nurse to tell the patient about colostomy odor? 1. "It occurs only when the colostomy appliance is changed." 2."It is caused by certain foods that can be omitted from the diet." 3. "It is mainly caused by poor hygiene and can be remedied." 4. "It is far more noticeable to the patient than to others."

2."It is caused by certain foods that can be omitted from the diet."

The nurse is assisting with monitoring the function- ing of a chest-tube drainage system in a client who just returned from the recovery room after a thora- cotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply. 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 ml. of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water. seal chamber during inhalation and exhalation

3. 50 ml. of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water. seal chamber during inhalation and exhalation

The nurse is caring for a patient with a new ostomy. What is the best nursing strategy for encouraging patient self-care of an ostomy? 1. Plan to change the pouch when family members will be present, have the patient watch, and have the patient and family listen to the procedure. 2. Frequently tell the patient that if he or she does not learn stoma self-care, no one is going to do it for him or her. 3. Encourage the patient to watch the stoma care procedure, gradually encouraging participation. 4. Shield the patient from sight of the stoma until the patient actually asks to see it.

3. Encourage the patient to watch the stoma care procedure, gradually encouraging participation.

A nurse is preparing to insert a nasogastric tube. The nurse? should place the patient in which position? 1. On the right side. 2. Low Fowler position. 3. High Fowler position. 4. Supine with head of bed flat.

3. High Fowler position.

The nurse is administering a cleansing enema. Before administering the enema, the nurse assists the patient into which position? 1. Supine 2. On right side 3. Left Sims position 4. Left side with head of bed elevated 45 degrees

3. Left Sims position

If the patient is suspected of having a fecal impaction, which type of enema would the nurse anticipate the health care provider to order? 1. Soapsuds enema 2. Polystyrene sulfonate enema 3. Oil retention enema 4. Tap water enema

3. Oil retention enema

The nurse is assigned to assist with caring for a di ent with esophageal varices who had a Sengstaken. Blakemore tube inserted because other treatment measures were unsuccessful. The nurse would check the client's room to ensure that which priority item is at the bedside? 1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors

4. A pair of scissors

What is considered a noninvasive method of collecting urine for the incontinent patient? 1. Suprapubic catheterization 2. Reinsertion of a Foley catheter 3. Catheter irrigation 4. Condom catheterization

4. Condom catheterization

The nurse is instructing the patient in performing Kegel exercises. The patient should be instructed to contract the muscles he or she would use to stop the flow of urine. What is the proper technique for performing Kegel exercises? 1. Contract for 3 to 4 seconds and relax for 3 to 4 seconds. 2. Contract for 3 to 4 seconds and relax for 10 seconds. 3. Contract for 10 seconds and relax for 3 to 4 seconds. 4. Contract for 10 seconds and relax for 10 seconds.

4. Contract for 10 seconds and relax for 10 seconds.

The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause which complication? (Select all that apply.) 1. Fungal infection 2. Bacterial infection 3. Yeast infection 4. Irritation of the stoma 5. Skin breakdown around the stoma

4. Irritation of the stoma 5. Skin breakdown around the stoma

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which meth- od would be used to monitor the client for crepitus? 1. Auscultating the posterior breath sounds 2. Asking the client about pain upon inspiration 3. Placing the hands over the rib area and observing expansion 4. Palpating the skin around the chest and neck for a crackling sensation

4. Palpating the skin around the chest and neck for a crackling sensation

When providing routine indwelling catheter care, the nurse should be most diligent in cleaning which areas? 1. The perineal area 2. The area surrounding the urinary meatus 3. The labia majora and the labia minora 4. The perineal area and 2 inches of the catheter

4. The perineal area and 2 inches of the catheter

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing, When would the nurse inflate the balloon? 1. Immediatelv 2. When resistance is met 3. After inserting the catheter an additional 2.5 to 5 cm 4. When the catheter is advanced to the point of bi- furcation

4. When the catheter is advanced to the point of bi- furcation

Enema

a liquid that is pushed into rectum to help with bowel movement

Colostomy

a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon.

Urinary Catheter

a tube that is pushed through the urinary meatus and urethra into the bladder

Urostomy

allows urine to leave body through a surgical bypass directly outside of the body through a stoma

ileostomy

an opening in the belly (abdominal wall) that's made during surgery.

Catheterization

equipment that is used to drain the bladder

fecal impaction

extreme constipation

Flatulence

gas in the stomach or intestines

Defecation

to have a bowel movement

Irrigation

washing out a organ with a continuous flow of water or medication

Dumping syndrome

when food is dumped into small colon from stomach too quickly after eating