Exam 4 210 - Prep U

A nurse is assessing a patient's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? Contact the primary care provider to report this finding. Irrigate the ostomy to clear a possible obstruction. Document a nursing diagnosis of Impaired Skin Integrity. Document that the stoma appears healthy and well perfused.

Document that the stoma appears healthy and well perfused.

A nurse is preparing to place a patient's ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube? A)Place distal tip to nose, then ear tip and end of xiphoid process .B)Instruct the patient to lie prone and measure tip of nose to umbilical area. C)Insert the tube into the patient's nose until secretions can be aspirated. D)Obtain an order from the physician for the length of tube to insert.

Place distal tip to nose, then ear tip and end of xiphoid process.

Tube feedings are given to a patient after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which of the following measures should the nurse include in the care plan to reduce the risk of aspiration? Place patient in semi-Fowler's position during, and 60 minutes after, an intermittent feeding. Change tube feeding container and tubing. Avoid cessation of feedings. Administer 15 to 30 mL of water before and after medications and feedings.

Place patient in semi-Fowler's position during, and 60 minutes after, an intermittent feeding.

To reduce urethral irritation, where should the nurse tape the female client's Foley catheter? groin area lower thigh lower abdomen inner thigh

inner thigh

The nurse is teaching a client about continuous bladder irrigation (CBI) following prostate surgery/ What should the nurse tell the client? "The catheter is clamped off approximately 4 hours after you return to the nursing unit." "The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder." "The catheter is disconnected from the drainage tubing one time per shift to enable manual irrigation of the bladder." "The fluid drips into the bladder at a slow rate to prevent the effects of overhydration and hyponatremia."

"The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder."

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? 8 6 10 4

4

Which finding would indicate bowel functioning is returning after anesthesia and surgery for a client with a nasogastric tube? Inspection of the contour of the abdomen indicates no distension. Percussion indicates tympany over the abdomen. Palpation around the surgical site indicates a soft, pliable abdomen. Auscultation indicates bowel sounds in all four quadrants.

Auscultation indicates bowel sounds in all four quadrants.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube? Maintain the client on bed rest during the feedings. Check the gastrostomy tube for position every 2 days. Change the tube feeding administration set at least every 24 hours. Maintain the head of the bed at a 15-degree elevation continuously.

Change the tube feeding administration set at least every 24 hours.

The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first? Reposition the NG tube. Irrigate the NG tube. Check the function of the suction equipment. Call the health care provider (HCP).

Check the function of the suction equipment.

A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which action by the nurse would be most appropriate? Administer an analgesic and antiemetic as ordered. Explain that nausea is common because the NG tube irritates the gag reflex. Irrigate the NG tube with water and give an analgesic as ordered. Check the patency and amount of drainage from the NG tube.

Check the patency and amount of drainage from the NG tube.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? Having the patient frequently rate his or her hunger on a 10-point scale Checking the patient's capillary blood glucose levels regularly Monitoring the patient's level of consciousness each shift Measuring the patient's heart rhythm at least every 6 hours

Checking the patient's capillary blood glucose levels regularly

The nurse should begin the process of removing a patient's nasogastric (NG) tube by doing which of the following? Separating the tube from suction Confirming the placement of the NG tube Confirming the physician's order to remove the tube Flushing the tube with 10 mL of water or normal saline

Confirming the physician's order to remove the tube

A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client? Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube. Cut the tablets in half and wash them down the NG tube, using a water-filled syringe. Crush the tablets and wash the powder down the NG tube, using a syringe filled with saline solution. Heat the tablets until they liquefy; then pour the liquid down the NG tube.

Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube.

A patient has received a temporary ostomy during her treatment for colon cancer. Which of the following techniques is most likely to facilitate the patient's ability to independently empty and change the ostomy after discharge? Demonstration Discussion Lecture A brochure

Demonstration

A student nurse is administering medications through a nasogastric tube connected to continuous suction. How will the student do this accurately? Briefly disconnect tubing from the suction to administer medications, then reconnect. Realize this can't be done, and document information. Disconnect tubing from the suction before giving drugs, and clamp tubing for 20 to 30 minutes. Leave the suction alone and give medications orally or rectally.

Disconnect tubing from the suction before giving drugs, and clamp tubing for 20 to 30 minutes.

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? Change the filter on the tubing, and continue with the infusion. Continue the infusion until the remaining 300 mL is infused. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution. Notify the health care provider (HCP), and obtain prescriptions to alter the flow rate of the solution.

Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate for the nurse to follow when administering a drug via this route? Position the patient supine prior to administering the drug. Flush the tube with water between each drug administered. If connected to suction, do not reconnect to suction for 5 minutes after drug administration. Administer the medication at a cold temperature.

Flush the tube with water between each drug administered.

Which of the following types of feeding tubes would be most appropriate for a patient requiring enteral feeding for a long period of time? Gastrostomy tube Salem sump tube Nasogastric tube Nasointestinal tube

Gastrostomy tube

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is Irritating the epiglottis Coiling in the client's mouth Passing into the esophagus Inserted into the lungs

Inserted into the lungs

A nurse drains the bladder of a patient by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? Indwelling urethral catheter Retention catheter Foley catheter Intermittent urethral catheter

Intermittent urethral catheter

The nurse is providing care to a client who has had a transurethral resection of the prostate. The client has a three-way catheter drainage system in place for continuous bladder irrigation. The nurse anticipates that the catheter may be removed when the urine appears as which of the following? Light yellow and clear Light pink with few red streaks Reddish-pink with numerous clots Dark amber with copious mucous

Light yellow and clear

The client has a continuous bladder irrigation after a transurethral resection. Which is a nursing goal related to maintaining the irrigation? Perform activities of daily living. Recognize signs of prostate cancer. Maintain catheter patency. Reduce incisional bleeding.

Maintain catheter patency.

Which nursing assessment is recommended to confirm placement of the nasogastric (NG) tube into the stomach of a client? Measure NG tube length to confirm it is equal to the distance from the client's ear lobe to the nose plus the distand from the nose to the tip of the xiphoid process. Obtain a chest X-ray and measure the pH of stomach contents. Apply the stethoscope to the xiphoid process and instill 50 mL of air into the tube and listen for a gurgling or popping sound. Measure to the second or third black marking on the NG tube.

Obtain a chest X-ray and measure the pH of stomach contents.

A nurse performing continuous bladder irrigation on a patient notes that hourly drainage is less than amount of irrigation being given. Which of the following interventions would be appropriate in this situation? Select all that apply. Lower the bag 3 to 6 inches and recheck the patient. Roll the patient onto his or her back Remove the catheter in place. Check to make sure that the tubing is not kinked. If return flow remains decreased, notify the physician. Palpate for bladder distention.

Palpate for bladder distention. Check to make sure that the tubing is not kinked. If return flow remains decreased, notify the physician.

A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action? Prevent gastric ulcers Prevent aspiration Prevent abdominal distention Prevent diarrhea

Prevent aspiration

A nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure? prone supine dorsal recumbent Sims' left lateral

Sims' left lateral

The nurse is caring for a 13-year-old client with ulcerative colitis who has a new temporary colostomy. Which nursing intervention is priority? Teach the client how to perform colostomy care. Set up home health care for the client. Encourage the parents to care for the child. Discuss the process for colostomy reversal with the client.

Teach the client how to perform colostomy care.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? The graduate uses a room temperature solution. The graduate places the client in Fowler's position. The graduate advises the client that the enema should not be expelled immediately. The graduate takes this opportunity to teach about the function of the intestinal tract.

The graduate places the client in Fowler's position.

Insertion of a nasogastric tube into a patient who has facial fractures can result in misplacement of the tube into the patient's brain. True False

True

Which of the following is the best method for determining nasogastric tube placement? Observation of gastric aspirate Placement of external end of tube under water X-ray Testing of pH of gastric aspirate

X-ray

A client who had a transurethral resection of the prostate (TURP) has a three-way indwelling urinary catheter with continuous bladder irrigation. In which circumstance should the nurse increase the flow rate of the continuous bladder irrigation Increase it when drainage: becomes bright red. is continuous but slow. appears cloudy and dark yellow. of urine and irrigating solution stops.

becomes bright red.

The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem? friction along the urethra when the catheter is being inserted spasms at the orifice of the bladder the formation of encrustations that may occur at the end of the catheter the number of organisms gaining entrance to the bladder

friction along the urethra when the catheter is being inserted

A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours, the tube has drained 2 L of fluid. The nurse should further assess the client for which electrolyte imbalance? hypermagnesemia hypocalcemia hypernatremia hypokalemia

hypokalemia

The nurse administers fat emulsion solution during TPN to a malnourished client. What should the nurse tell the client about the purpose of this solution? Fat emulsion solution: maintains a normal body weight. adds extra carbohydrates. promotes effective metabolism of glucose. provides essential fatty acids.

provides essential fatty acids.

A client has been receiving total parenteral nutrition (TPN) for the last 5 days. Before the nurse discontinues the infusion, the infusion rate is slowed. What complication of TPN infusion should the nurse assess the client for as the infusion is discontinued? dehydration malnutrition essential fatty acid deficiency rebound hypoglycemia

rebound hypoglycemia

A client has returned from surgery with continuous bladder irrigation. The nurse is aware that proper maintenance of a continuous bladder irrigation system includes: regulating irrigant flow to maintain red urine. maintaining a slow flow rate of irrigant to prevent bladder distention. regulating irrigant flow to maintain pink urine. stopping the irrigation if there's leakage of large amounts of urine around the catheter.

regulating irrigant flow to maintain pink urine.

Which laboratory test is the best indicator of a patient in need of TPN? serum albumin creatinine hemoglobin hematocrit

serum albumin

The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a nosocomial infection? heat lamp urinary catheterization enema intramuscular injections

urinary catheterization