NCLEX Questions- Care of a Client with a tube

The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medications? 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 of less than 3.5

1,2,3, and 5. Rationale-By aspirating stomach contents the residual volume can be determined and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume, in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is antinvasive procedure and is unnecessary.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control 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. Immediately clamp the chest tube and notify the health care provider

1. Rationale-Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. Increasing the suction pressure only increased the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).

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. Rationale-Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider.

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? 1. 3.5 2. 7.0 3. 7.35 4. 7.5

1. Rationale-If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates hace acidic values and should be 3.5 or lower. Option 2 indicates a slightly acidic pH. Option 3 indicates a neutral pH. Option 4 indicates an alkaline pH.

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 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. Rationale-Unless specifically indicated, residual amounts more than 100 mL, require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

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 nursing action should the nurse take? 1. Call the health care provider 2. Place the tube in a bottle of sterile water 3. Immediately replace the chest tube system 4. Place a sterile dressing over the disconnection site

2. Rationale-If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.

While changing the tapes on a tracheotomy 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. Rationale-If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Calling ancillary services or the HCP will delay treatment in this emergency situation. Covering the tracheostomy sire will block the airway.

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 exhlation

3,4,5, and 6. Rationale-The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100mL/hour is considered excessive and requires health care provider notification. The chest tube insertion site is covered with an occlusive (air-tight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

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 2. Mark the tube at 32 inches 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. Rationale- Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches. The remaining options identify incorrect procedures for measuring the length of the tube.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medicaton, 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. Rationale-If a client has a nasogastric tube sonnected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

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

4. Rationale-During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

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. Exhales slowly 2. Stay very still 3. Inhale and exhale quickly 4. Perform the Valsalva maneuver

4. Rationale-When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an air-tight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.