Skills - HESI

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."

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing.

-Close the roller clamp on the IV tubing -Spike the IV bag and half-fill the drip chamber -Open the roller clamp and fill the tubing -Uncap the distal end of the tubing. -Attach the distal end of the tubing to the client.

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure?

-Place pt in a semi Fowler's -Turn on suction device and set the regulator at 80 mm Hg -Attach suction tubing to suction catheter -Hyperoxygenate pt -Insert catheter into tracheostomy until resistance is met, and then pull it back 1 cm. -Apply intermittent suction and slowly withdraw catheter while rotating it back and forth

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?

Percussion and vibration

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?

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 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?

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.

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter?

Sterile 2 × 2 gauze

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Stop the irrigation temporarily.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

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 is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication?

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

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 administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action?

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

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client?

Ensure that a sterile safety pin is through the drain.

The nurse is administering a bolus feeding through nasogastric (NG) tube. Which position should the nurse use for the client after the tube feeding?

Fowler's on the right side. gravity helps facilitate gastric emptying, which reduce vomiting.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?

High Fowler's

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?

Left Sims' position

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?

Oil-soluble lubricant. Use Water-soluble lubricant instead.

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution should the nurse use for the irrigation?

Tap water. If the tap water is not suitable for drinking, bottled water should be used.