Week 3 Lab Skills

Use soap and sterile 0.9% sodium chloride solution in place of povidone-iodine

1. A nurse is caring for a child who needs a catheter placed, but the child has an allergy to povidone-iodine. How should the nurse proceed? A. Do not perform the procedure because the child cannot have a catheter placed. B. Use soap and sterile 0.9% sodium chloride solution in place of povidone-iodine. C. Cleanse with povidone-iodine, followed by soap and water. D. Use lidocaine in place of povidone-iodine.

Basilar skull fracture Rationale: NG and OG tubes are contraindicated in a patient with a suspected basilar skull fracture or maxillofacial trauma because of the risk of inadvertent tube placement into the brain. NG and OG tubes are not contraindicated for use in a patient who has a cervical spine injury or is receiving mechanical ventilation. NG or OG tubes can be used for gastric air decompression.

10. A patient has been prescribed NG tube feedings by the trauma surgeon. The presence of which factor in this patient's situation would cause the nurse to question the surgeon's order? A. Basilar skull fracture B. Cervical spine injury C. Mechanical ventilation D. Gastric distention

"I will clean the area around the catheter every day with warm soapy water."

10. The child is to be discharged with an indwelling catheter. In teaching the family regarding hygiene, which of the following statements by the family demonstrates understanding of the teaching? A. "I will only allow sponge baths until the catheter is removed." B. "I will clean the area around the catheter every day with warm soapy water." C. "I will clean the area around the catheter every day with alcohol." D. "I will apply antibiotic ointment to the area around the catheter every day."

Change the gauze dressing. A gauze dressing is replaced every 2 days, so the IV site dressing is due to be changed. With an IV site that may bleed or ooze, a gauze dressing should be used. Reinforcing with a pressure dressing is not indicated because the dressing is due to be changed. The dressing should be changed again if it becomes loose or soiled; however, this dressing is due to be changed now.

5. A nurse assesses the IV site of a patient with a diagnosed bleeding disorder. The IV dressing was placed 2 days ago, and the nurse notes that there is blood on the gauze under the IV dressing. What should the nurse do? A. Replace the gauze dressing with a transparent dressing. B. Reinforce the gauze dressing with a pressure dressing. C. Change the gauze dressing. D. Change the dressing if it is loose.

Attempt to flush the tube Rationale: With a sudden, significant drop in output, the nurse should check for a clogged tube by flushing it. Checking the pH is useful for determining proper placement, which should be done if the tube flushes easily. Turning the patient onto the left side will not help. Replacing the tube should be done if it is not functioning properly and cannot be flushed

6. A nurse is assessing a patient who was admitted 24 hours earlier with a bowel obstruction and who now has an NG tube in place for gastric decompression. The patient's NG output was more than 400 ml for 12 hours, but the nurse observes that there has been no NG output for the past 2 hours. What should the nurse do? A. Check the pH of the aspirate. B. Replace the tube. C. Turn the patient onto the left side. D. Attempt to flush the tube.

From nose to earlobe, then from earlobe to midpoint between xiphoid process and umbilicus Rationale: Recent studies indicate that of these measurements, the most accurate predictor of correct NG tube length is from the tip of the nose to the earlobe, then from the earlobe to the midpoint between the xiphoid process and the umbilicus. Measuring to the xiphoid process is incorrect and could result in the tube being placed too high. Measuring from the corner of the mouth to the umbilicus may result in the tube being placed past the stomach and is not the recommended measurement. Measuring to the midpoint between the manubrium and xiphoid process could result in the tube being placed too high.

8. To determine where to mark the correct length on an NG tube for a 2-month-old patient, how should the nurse measure? A. From nose to earlobe, then from earlobe to xiphoid process B. From nose to earlobe, then from earlobe to midpoint between xiphoid process and umbilicus C. From corner of mouth to earlobe, then from earlobe to umbilicus D. From corner of mouth to earlobe, then from earlobe to midpoint between manubrium and xiphoid process

Notify the practitioner.

A 3-year-old patient with a GT pulls out the GT button inadvertently. The gastric opening is now bleeding, and the stoma is enlarged. Which action should the nurse take? A. Insert a smaller GT button device. B. Notify the practitioner. C. Insert a urinary catheter. D. Insert a larger GT button device.

Placing an OP airway to relieve the obstruction by the tongue Rationale: An OP airway helps to relieve the obstruction by lifting the tongue away from the posterior pharyngeal wall. The obstruction results from the laxity of the tongue, not from the patient biting down on it. An NP airway is contraindicated in a patient with facial fractures.

A 5-year-old patient with a traumatic brain injury and multiple facial fractures begins having seizures and becomes apneic, requiring manual ventilation via a bag-mask device. The team has difficulty ventilating the obtunded patient whose airway is obstructed because of tongue laxity. Which intervention is the most appropriate? A. Placing an OP airway to prevent the patient from biting down on the tongue B. Placing an NP airway to maintain patency of the nares C. Placing an OP airway to relieve the obstruction by the tongue D. Placing an NP airway to provide a conduit from the nares to the pharynx

Aspirate stomach contents Rationale: GT placement is initially determined by aspirating stomach contents. Radiographic imaging should be considered only if concern remains regarding the location of the GT after aspiration of stomach contents or if the gastrostomy was performed recently. GTs can be accessed and used immediately after replacement; a 4-hour waiting period is not necessary and does not help to determine placement. The balloon remains inflated for use

A GT placed 2 years ago was recently replaced after an inadvertent dislodgment. Before resuming enteral feeds, what should the nurse do first? A. Wait 4 hours and deflate the balloon before restarting feeds. B. Confirm placement with radiographic imaging. C. Apply low suction to the GT for 4 hours after replacement. D. Aspirate stomach contents.

Notify the practitioner. Rationale: A newly placed GT should be reinserted only by a practitioner to prevent damage to the site and internal tract. The GT site can close quickly, but the nurse should not attempt to insert a new or the existing GT into the surgical site because it could be misplaced into the peritoneum. The GT tract takes at least 30 days to mature; a tube that has become dislodged before it has been in place for 30 days should be replaced only by the practitioner. A practitioner may place a urinary catheter one size smaller than the GT; a larger urinary catheter could be painful and damage the surrounding tissue.

A GT placed during surgery has become dislodged within the first few hours postoperatively. Which action should the nurse take? A. Clean the GT button and reinsert it. B. Immediately insert a new GT button. C. Notify the practitioner. D. Insert a large urinary catheter.

Distention when palpating the bladder. Rationale: The presence of distention when palpating the bladder indicates possible obstruction of the urinary catheter from sediment or blood clots. Other reportable conditions include no urine drainage in several hours and excessive, cloudy, or bloody drainage from the urethral meatus. Amber-colored urine is a normal variation: the color of the urine can vary with fluid status or even medication usage. For a child to have no urine output for several minutes is normal, especially if the child is diuretic-dependent. No drainage from the urethral meatus is a normal finding.

A child in the intensive care unit with an indwelling urinary catheter has a decrease in urine output. What other assessment information should be reported to the practitioner along with the decrease in output? A. No urine output for several minutes B. Distention when palpating the bladder C. Amber-colored urine D. No drainage from the urethral meatus

A urethral tear Rationale: A suspected urethral tear is an absolute contraindication to inserting a urinary catheter; injury to the urethra may lead to a misplaced catheter or further injury during insertion. Placement of an indwelling catheter is appropriate for a child in the case of urologic surgery or bladder obstruction. A femoral central line does not exclude catheter placement.

A child needs a urinary catheter. Which situation would be a contraindication to placing a urinary catheter? A. A urethral tear B. Urologic surgery C. Bladder obstruction D. A femoral central line

Obtain a specimen and send it to the laboratory. Rationale: Blood in the urine could result from irritation from the earlier catheterization, or it may indicate a more serious condition such as infection. An indwelling catheter is not indicated at this time. A urine culture should not be diluted because this alters the characteristics of the urine sent to the laboratory. The nurse should finish the procedure because the results could help with the diagnosis.

A child underwent catheterization for a urinalysis earlier in the shift. Later, a fever developed, and an order was written for a urine culture. On catheterization, the nurse notes bloody urine. Based on this information, which action is the most appropriate? A. Obtain a specimen and send it to the laboratory. B. Leave the catheter in place to allow continuous drainage. C. Flush the catheter with sterile water before obtaining the specimen. D. Notify the practitioner that the urine was contaminated

Apply warm compress on the bladder Application of a warm compress is an appropriate action to help alleviate bladder spasm. This is an expected finding and reporting symptoms to the physician is not the best response. Starting IV antibiotics is not appropriate. Increase rate of IV fluid is not an appropriate action from the nurse.

A child with a suprapubic catheter reports bladder spasm. Which of the following is the best action from the nurse? A. Report symptoms to the physician B. Start IV antibiotic, as prescribed C. Apply warm compress on the bladder D. Increase rate of IV fluid

The catheter is covered with a dressing Covering the catheter with a dressing helps prevent the child from removing the catheter. Keeping the catheter uncovered increases the risk for the child to pull the catheter. Restraining the child is not appropriate. Teaching the child how to use the catheter is not necessary.

A developmentally appropriate 3-year old child has a suprapubic catheter. Which of the following is most important for the nurse to ensure? A. The catheter remains uncovered B. The child is in soft wrist restraints C. The child is taught how to use the catheter D. The catheter is covered with a dressing

Keeping a gloved finger over the insertion site throughout the dressing change Rationale: Keeping a finger in place over the catheter during a dressing change decreases the risk for inadvertent dislodgment. Fanning the insertion site would not be appropriate for infection control. Placing gauze under the wings of the catheter to avoid tape would increase the risk of catheter kinking. A gauze dressing or skin protectant would be better suited for a diaphoretic patient than adding tape.

A new nurse is following a member of the IV team for a day to observe placement of peripheral VADs. Which action by the new nurse indicates learning? A. Fanning the insertion site after cleansing to accelerate the drying time B. Tucking gauze under the device's wings to avoid adding tape to the skin of a premature infant C. Adding tape around the edge of the transparent occlusive dressing on a diaphoretic patient D. Keeping a gloved finger over the insertion site throughout the dressing change

Leaking Rationale: Leaking is an expected occurrence if the catheter is not secure. Systemic infection is a risk of a suprapubic catheter. Local infection can occur with a suprapubic catheter. Bladder spasms can occur with the presence of a suprapubic catheter.

A nurse assesses a patient's suprapubic catheter and sees it is not secured to the patient's abdomen. Which of the following can the nurse expect? A. Leaking B. Systemic infection C. Local infection D. Bladder spasm

Check the new GT balloon for leaks by injecting sterile water into it.

A nurse called to a pediatric patient's room by the family determines that the patient's GT has become dislodged after being in place for 3 months. After removing the GT and before inserting a new one, which action should the nurse take? A. Complete a preoperative checklist to prepare the patient for surgery. B. Check the new GT balloon for leaks by injecting sterile water into it. C. Pass a nasogastric tube into the gastric opening to decompress the stomach. D. Explain to the family that a wire stylet will be used to guide the GT into place.

Cephalic vein Rationale: The best access site for a venous catheter in this patient is the right cephalic vein. The dorsal venous arch and the saphenous veins are located in the feet and are not recommended in a pediatric patient of walking age. The frontal vein, located in the scalp, should be used only in an infant.

A nurse has orders to start a PIV infusion for a school-age patient. Which site is best for venous catheter placement in this patient? A. Cephalic vein B. Saphenous vein C. Dorsal venous arch D. Frontal vein

Aseptic technique Rationale: Aseptic technique is appropriate to use for cleaning the site. Strict sterile technique is not appropriate. Clean technique is not the best answer. Sterile technique is not necessary for this procedure.

A nurse is preparing to clean the site of a patient's established suprapubic catheter insertion. Which of the following is the most appropriate technique to use? A. Aseptic technique B. Strict sterile technique C. Clean technique D. Sterile technique

The foreskin is left in a retracted position after catheter insertion. Paraphimosis occurs when the foreskin is left in a retracted position and if left untreated could lead to necrosis of the glans penis. The penis is cleansed from urethra to and including the edge of the glans. Hold the phallus relatively perpendicular to the child's body to facilitate passage of the catheter. Urine visualization alone cannot assure placement of the catheter into the bladder. Advancing to the "Y" connector or hub in the male child ensures that the balloon isn't inflated while in the prostatic urethra, which would cause pain and bleeding.

A nurse is supervising a novice nurse catheterizing an uncircumscribed male infant. Which of the following observations would require the preceptor to intervene and correct the novice nurse's technique? A. The head of the penis is cleansed to the outer edge of the glans. B. The penis is held at a 90-degree angle from the body for catheter insertion. C. The catheter is inserted up to the "Y" connector or hub. D. The foreskin is left in a retracted position after catheter insertion.

Urine output of 40 ml by 4 hours after remov Rationale: Urine output of 2 ml/kg/hr is the average output goal for an infant; therefore, 40 ml of urine after 4 hours is appropriate. Urine output of 10 ml in 4 hours is inadequate, as is 30 ml in 8 hours; both should be reported to the practitioner. The inability to void 4 hours after urinary catheter removal is not expected because the infant should have voided 2 ml/kg/hr by this time.

A nurse is taking care of an infant who recently had an indwelling urinary catheter removed. The infant weighs 5 kg (11 lb). What is an appropriate urine output postprocedure for this infant? A. No urine output within 4 hours after removal B. Urine output of 30 ml by 8 hours after removal C. Urine output of 10 ml by 4 hours after removal D. Urine output of 40 ml by 4 hours after removal

Clean in a circular motion Rationale: Cleaning the exit site in a circular motion is the best way to prevent microorganisms or debris from entering the exit site. Cleaning the exit site is appropriate, but this is not the best response from the nurse preceptor. The exit site should be cleaned by the nurse. Stating that this is harmful in front of the patient is not the best response.

A nurse orientee is cleaning the exit site of a suprapubic catheter with an up-and-down motion. What is the best response from the nurse preceptor? A. "Cleaning the exit site is appropriate" B. "The exit site does not need to be cleaned" C. "Clean in a circular motion" D. "The way you are cleaning will harm the patient"

"It feels puffy and tight." Rationale: Swelling and a feeling of tightness at the IV insertion site indicates a probable infiltration. Itching could be an adverse effect or allergic response to the fluids being administered, and further assessment would be needed. Pulling of the skin from the tape could be a side effect of stabilization of the IV catheter; the site dressing may need to be replaced. A feeling of coldness could be normal if the fluids infusing are at room temperature

A nurse performs an assessment on a school-age patient's PIV site with continuous IV fluids infusing. What statement by the patient describes symptoms that most likely indicate a need for a new IV? A. "It itches." B. "The tape is pulling my skin." C. "It feels cold." D. "It feels puffy and tight."

Attach a double-lumen add-on to the IV site. Rationale: A double-lumen add-on will allow both medications to infuse to the same line. Administering the medications separately is not necessary because they are compatible. Starting another IV is not indicated at this time. Attaching both an add-on connector and a y-site tubing is not necessary, and add-ons should be limited to the least number needed.

A patient is due for two compatible IV medications to be infused at the same time. Which action should the nurse take? A. Administer the medications back-to-back. B. Attach a double-lumen add-on to the IV site. C. Insert another PIV catheter and give both medications. D. Attach an add-on connector and a y-site tubing.

The NP airway is too long. Rationale: Bradycardia is associated with a NP airway that is too long because it stimulates a vagal response. A short NP airway would not cause bradycardia. Although bearing down, as in trying to have a bowel movement, could potentially cause a vagal response, this would be highly unlikely in this particular situation. A patient experiencing pain would most likely have tachycardia.

A patient with a newly inserted NP airway in place is experiencing episodes of bradycardia with a decrease in heart rate from 110 beats per minute to 70 beats per minute within 1 hour of insertion. The patient does not have any underlying cardiac problems. What is the most likely cause of the patient's symptoms? A. The NP airway is too short. B. The patient is trying to have a bowel movement. C. The NP airway is too long. D. The patient is experiencing pain.

Check the extremity distal to the site for infiltration. Rationale: If there is an opaque dressing in place, the extremity distal to the site should be monitored for signs of infiltration. Asking a patient if he or she is willing to have another peripheral IV catheter placed is not a valid assessment tool. Turning up the alarm limits would not be considered safe practice. There is no need to remove the dressing if it is intact when there are other ways to monitor the IV site.

A young patient is reporting pain at the IV site, and the infusion pump alarms high pressure. The dressing is opaque and the patient has been using that hand to play video games. The nurse asks the patient if it hurts enough to be taken out and have another peripheral IV catheter placed. The patient answers no. What should the nurse do next? A. Check the extremity distal to the site for infiltration. B. Increase the pressure limit and continue to monitor. C. Nothing, since the patient says it does not hurt very much. D. Remove the dressing and check the site for infiltration.

Occlude the tube by bending it. Rationale: Before removing an NG tube that has been used for gastric decompression, the nurse must occlude the tube to help prevent the aspiration of gastric fluid into the lungs. Offering a pacifier, measuring the patient's abdominal girth, and assessing the patient's gag reflex are not necessary when the NG tube is removed but are important components of care when the patient needs nonnutritive sucking, when feeding tolerance is monitored, and when oral feedings are initiated, respectively.

An infant has an NG tube in place after surgery. The patient no longer needs the tube. Before removing the tube, what must the nurse do? A. Measure the patient's abdominal girth. B. Offer the patient a pacifier. C. Occlude the tube by bending it. D. Assess the patient's gag reflex.

By pulling the opposing edges parallel to the skin to loosen the bond Rationale: The best way to remove a transparent dressing is by pulling from the opposing edges until the bond is loosened. Soaking an IV site in water increases the risk of infection at the site. Because the transparent dressing can be pulled off easily, the nurse should not use scissors. Removing the transparent dressing from the center could cause the catheter to dislodge.

An infant is being discharged to home. Before removing the infant's IV line, the nurse explains to the family that the transparent dressing will be removed by which method? A. By soaking the IV site in warm water to loosen the adhesive bond B. By pulling the opposing edges parallel to the skin to loosen the bond C. By cutting the transparent dressing from the edge farthest from the IV insertion site D. By pulling back from the center of the dressing while holding the hub

A radiograph of the abdomen Rationale: An abdominal radiograph is the recommended method for confirming placement of a postpyloric feeding tube because of its reliability. Although pH testing is reliable, pH is acidic only in the stomach; with a postpyloric tube, the pH will be neutral or alkalotic depending on placement. Obtaining residual volumes does not indicate correct placement of the tube because some mixing of gastric and intestinal fluid can occur. Auscultation is unreliable because sounds can be transmitted to the epigastric area regardless of actual location.

During a teaching session, the nurse informs the patient's family that placement of a postpyloric tube is most reliably confirmed by which method? A. An acidic pH of aspirated contents B. A radiograph of the abdomen C. Checking for residual volumes D. Auscultation of insufflated air

Provide more frequent mouth care. Rationale: OG or NG tubes may cause mouth breathing, which may dry the mouth and increase the risk of mucosal breakdown and ulceration; therefore, frequent mouth care is required and the practitioner should be notified if the condition worsens. Replacing an OG tube with an NG tube does not solve the problem. The patient with a decompression tube is getting nothing by mouth because the goal is to keep the stomach decompressed. Oxygen administration is not indicated because this patient's respiratory status is not compromised.

During assessment of a patient with an orogastric tube for gastric decompression in place, the nurse observes dry and irritated oral mucous membranes. How should the nurse proceed? A. Provide the patient with oxygen via a nasal cannula. B. Remove the OG tube and replace it with an NG tube. C. Provide the patient with frequent sips of water. D. Provide more frequent mouth care.

Aspirate the remaining vesicant agent from the catheter. Before discontinuation of a peripheral IV catheter because of extravasation of a vesicant agent, any vesicant should be aspirated to limit injury to the tissues. The provider should be notified, the infusion should be stopped, and the affected extremity should be elevated. However, aspirating the remaining vesicant agent should be done before the IV catheter is removed. An antidote may need to be administered through the site before removal.

If there is an extravasation of a vesicant agent, what should the nurse do first? A. Notify the provider and initiate the ordered treatment. B. Stop the IV infusion and remove the catheter. C. Elevate the extremity and place a warm pack at the insertion site. D. Aspirate the remaining vesicant agent from the catheter.

When the dressing is wet and peeling off Rationale: If the integrity of the IV dressing is compromised, it should be changed. Transparent, semipermeable IV dressings may remain in place for 5 to 7 days unless the dressing's integrity is compromised. The IV insertion site has a transparent dressing, so the IV site would be visible. A gauze dressing—which may be used if the patient is diaphoretic or there is bleeding or oozing at the site—should be replaced every 2 days.

In which situation should a transparent, semipermeable dressing on an IV insertion site be changed? A. Two days after the initial IV dressing was placed B. One day after the last IV dressing change C. When the site is not visible through the dressing D. When the dressing is wet and peeling off

The device is flatter and thus more aesthetically pleasing. Rationale: Low-profile dome devices may be placed in patients who prefer the aesthetics of a flatter device. Disadvantages of the mushroom device are that insertion and removal can be painful; therefore, a local anesthetic is used. A low-profile GT does not allow frequent GT changes by a caregiver. Low-profile GT devices are not utilized for short-term feedings.

The family has requested a low-profile GT device for a patient. What is one advantage of this device? A. The device can be used for short-term feeding. B. Insertion and removal cause less pain. C. The GT can be changed frequently by the caregiver. D. The device is flatter and thus more aesthetically pleasing.

While you hold the patient, I'll remove one layer at a time, pulling laterally." Rationale: The dressing should be removed one layer at a time, pulling laterally to avoid dislodgment. The nurse performing the dressing change—not the assistant holding the patient—would use the dominant hand to remove the dressing and the nondominant hand to hold the cannula hub and tubing. Adhesive remover is used after the tape holding the cannula in place is removed, while the nurse stabilizes the catheter at the hub.

The nurse caring for a toddler is changing the IV site dressing because it has become loose. An assistant is helping by holding the toddler. Which statement by the nurse is appropriate for teaching the assistant? A. "I'll be quick and pull all of the dressing off at once to limit the time the toddler is held down." B. "Use your nondominant hand and pull the dressing away while I prepare the new dressing." C. "While you hold the patient, I'll remove one layer at a time, pulling laterally." D. "Wipe the entire dressing with adhesive remover to allow easy dressing removal."

Aspiration of stomach contents Rationale: After the GT has been inserted, the nurse gently aspirates the stomach contents to ensure placement. If the correct placement is in question, a radiologic GT study is obtained to confirm placement. Auscultation and palpation are not utilized in determining GT placement. Irrigation with 0.9% sodium chloride solution is not used to determine placement of a GT.

The nurse has inserted a GT. Which method is used to determine correct placement? A. Auscultation while injecting air B. Palpation of device C. Aspiration of stomach contents D. Irrigation with 0.9% sodium chloride solution

Replace the tube Rationale: The nurse should replace the tube because it is not properly placed in the stomach. Before administering an NG tube feeding, the nurse must verify the tube's placement to prevent administration of fluids into the lungs. Fluid from a tube properly placed in the stomach should test at a pH of 5 or lower. An accurate measurement of feeding residual can be obtained only after confirming the proper placement of the tube. Administering the feeding without verifying that the NG tube is in the stomach would be inappropriate. Auscultation of insufflated air into the stomach is not a recommended method for confirming NG tube placement.

The nurse is assessing a patient who has an NG tube in place for intermittent enteral nutrition. While preparing to administer a feeding, the nurse observes that the tape securing the tube to the patient's nose is loose. The nurse retapes the tube and then aspirates fluid from it. The pH of the aspirated fluid is 7. What should the nurse do next? A. Measure the residual. B. Administer the feeding. C. Auscultate while injecting air. D. Replace the tube.

Suction the oropharynx. Rationale: When caring for an infant receiving enteral nutrition by way of a feeding tube, the nurse should be prepared to initiate suction at the bedside if the patient vomits. Once the risk for aspiration is minimized, the nurse can continue the problem-solving process by determining the residual gastric volume and verifying tube placement in accordance with the organization's practice. Checking the pH of the patient's emesis and elevating the head of the bed are not pertinent in this clinical scenario.

The nurse is assessing an infant who is receiving enteral nutrition through an NG tube. During assessment, the patient coughs and vomits a small amount of thick fluid. What should the nurse do next? A. Suction the oropharynx. B. Check the pH of the patient's emesis. C. Assess the NG tube placement. D. Elevate the head of the bed to 45 degrees.

Flex the patient's head forward. Bending the patient's head forward makes aiming the NG tube posteriorly and parallel to the nasal septum, following the normal anatomy, easier. Placing the patient in Trendelenburg position hampers efforts because tube placement is more difficult with the anatomy in that position and increases the risk of aspiration. Tilting the patient's head backward opens the airway, increasing the possibility of tracheal intubation. Stabilizing the head maintains it in a midline position but does not permit flexion of the head; this may make correct placement of the tube more difficult.

The nurse is attempting to insert an NG tube into a 13-year-old patient with no cervical injuries. To facilitate passage of the NG tube with minimal trauma, what should the nurse do? A. Flex the patient's head forward. B. Place the patient in Trendelenburg position. C. Tilt the patient's head backward. D. Stabilize the patient's head.

The catheter has become knotted

The nurse is caring for a child with an indwelling catheter. There was no difficulty during insertion. The child has no external evidence of trauma or genitourinary abnormality. During removal of the catheter, the nurse can easily deflate the balloon and advance the catheter forward, but with gentle traction the catheter could not be withdrawn from the urethra. What is the most likely cause of this difficulty in removing the catheter? A. The catheter has become knotted B. There is a urethral tear C. The bladder is in spasm D. The child has a CAUTI

An NP airway is recommended for an awake, alert patient. NP airways are recommended for use in conscious patients with intact cough and gag reflexes. OP airways should not be used in an awake, alert patient because they can easily stimulate the gag reflex and may result in an obstruction rather than an opening of the airway. An OP airway is not used solely with an intubated patient; an OP airway may be used to open the airway when a patient with a natural airway is manually ventilated. Neither trisomy 21 nor an age of 24 months or younger are contraindications for the use of an OP airway.

The nurse is caring for an awake 14-month-old patient who has an airway obstruction and periodic desaturation. The patient is to receive an NP airway. What is the rationale for this decision? A. An NP airway is recommended for an awake, alert patient. B. An OP airway is contraindicated for a patient younger than 24 months old. C. An OP airway should be used only with an intubated patient. D. An NP airway is recommended only for a patient with trisomy 21.

Rinse the set with sterile water or place it in the refrigerator. Between bolus feedings, the nurse should either place the feeding set in a plastic bag and place the bag in the patient-specific refrigerator or rinse the feeding set with sterile water. Placing the feeding set in the refrigerator or rinsing it with sterile water have been shown to keep bacterial growth low. The set is not disposable after each use. It should not be washed with soapy water and should not be rinsed with tap water.

The nurse is delivering bolus tube feedings to a patient. After each feeding, what should the nurse do with the feeding set? A. Dispose of the set and obtain a new one for the next feeding. B. Wash the set with warm soapy water and allow it to air dry. C. Rinse the set with tap water and leave at the bedside. D. Rinse the set with sterile water or place it in the refrigerator.

Attempt to aspirate more sterile water from the balloon.

The nurse is experiencing some resistance while attempting to remove a urinary catheter from a child. What action should the nurse perform first? A. Attempt to aspirate more sterile water from the balloon. B. Cut the catheter from the balloon to make sure all the sterile water is out. C. Lubricate the catheter at the insertion site at the meatus. D. Pull on the catheter with minimal force.

"A topical anesthetic will be used before insertion." Rationale: A topical anesthetic, which can reduce pain during the procedure, should be applied before insertion to numb the area. The manufacturer's recommendations for organization-approved topical anesthetics should be evaluated for the length of time they must be in place to be effective. Pacifiers with sucrose have been found to be an effective comfort measure during needle-related procedures in infants up to 3 months old; however, this patient is a toddler. Positioning the patient's arm on an arm board may reduce vein irritation and prevent catheter dislodgment after the catheter is placed. The family should be given the option of being present during the insertion because their presence may comfort the patient.

The nurse is explaining the procedure for PIV catheter placement to the family of a toddler. Which statement by the nurse is the most appropriate regarding the patient's comfort during insertion? A. "Sucrose will be given during insertion." B. "A topical anesthetic will be used before insertion." C. "The extremity will be placed on an arm board." D. "Only the nurse placing the IV catheter will be in the room during insertion."

Use a needleless syringe to access the port Rationale: Urine for urinalysis or culture should be collected fresh from the needleless sample port of catheter tubing. Adherence to a sterile continuously closed method of urinary drainage markedly reduces the risk of acquiring a catheter associated infection. Breaches to the closed system should be avoided. Any specimen for culture from the drainage bag will be contaminated.

The nurse is inserting an indwelling urinary catheter. A urine culture and sensitivity has been ordered. Which technique should be used to obtain the specimen? A. Disconnect the catheter from the tubing. B. Use a sterile needle to pierce the catheter at the hub. C. Obtain from the drainage bag when recording intake and output. D. Use a needleless syringe to access the port.

D. Soap and water Rationale: The nurse may use soap and water as an alternate to povidone-iodine if the child is allergic. Alcohol could be irritating to the meatus. Normal saline and diaper wipes would not provide the necessary cleansing to limit the risk of infection and contamination of the specimen.

The nurse is planning to insert an intermittent catheter to collect a urine specimen. In the child's medical record, the nurse notices that the child has an allergy to povidone-iodine. Based on this information, what should the nurse use to clean the meatus? A. An alcohol wipe B. Normal saline solution C. Diaper wipes D. Soap and water

Have another staff member hold the child. A staff member should know how to correctly hold the child in an atraumatic manner and is prepared for the child to make sudden movements. The family should be involved where possible to assist with the procedure. They should not be responsible for holding the child. A toddler may interpret this as punishment. The family will not be able to anticipate the child's movements and protect the sterile field. Restrictive restraint techniques, such as a papoose board, should always be the last choice. Medication does not necessarily restrict the child's movements and should not be needed.

The nurse is preparing a toddler for catheter insertion. Which action can prevent contamination of the sterile field? A. Ask the family to hold the child. B. Place the child on a papoose board. C. Have another staff member hold the child. D. Ask the practitioner for an anxiolytic.

Hold the penis. Rationale: The nondominant hand should be used to grasp the penis and hold it so that it does not accidentally become contaminated after cleaning. The nondominant hand should be considered contaminated after touching the penis. All the other steps listed—cleansing the penis, retracting the foreskin, and inserting the catheter—should be performed with the dominant hand, which is still sterile.

The nurse is preparing to catheterize a male child. Just before the nurse cleanses the urethral meatus, what step should be taken with the nondominant hand? A. Cleanse the penis with antiseptic. B. Hold the penis. C. Insert the catheter. D. Retract the foreskin.

Most catheter manufacturers do not recommend testing the retention balloon

The nurse is preparing to place a urinary catheter in a child. Which statement should the nurse know to be correct about placing a urinary catheter? A. Do not pull back on the catheter after the retention balloon is inflated. B. Use the largest-size urinary catheter available for the child's procedure. C. Most catheter manufacturers do not recommend testing the retention balloon. D. Lubricate the catheter tip with an oil-based lubricant before insertion.

Encourage the child to assist with removing the first layer of tape. Rationale: Allowing the child to participate in removing the tape from the site provides her with a measure of control and often fosters cooperation. Although distraction is a good technique for calming a child during a procedure, the playroom is considered a safe place for a child and should not be used for procedures. IV sites may bleed when the cannula is removed, so the nurse should not guarantee that the site will not bleed. A local anesthetic is not appropriate for this procedure

The nurse is removing a peripheral IV from an anxious school-age child who is ready for discharge. Which action should the nurse take to help the child stay calm during the procedure? A. Distract the child by taking her to the playroom for a video game. B. Assure the child that the IV site will not bleed when the IV is removed. C. Use a local anesthetic to prevent any discomfort during the procedure. D. Encourage the child to assist with removing the first layer of tape

"I should hold the catheter securely throughout drainage." Rationale: While urine is draining, the nurse should hold the catheter securely to prevent inadvertent removal of the catheter before the bladder is completely drained. The nurse should palpate the bladder with the nondominant, not dominant hand, during removal to assess for complete emptying. The catheter should be withdrawn slowly and smoothly to minimize trauma. All specimens should be labelled at the bedside, in the presence of the child and family to prevent accidental mislabelling of specimens.

The nurse is teaching a nursing student to perform intermittent catheterization of a male child. Which statement by the nursing student demonstrates understands the teaching? A. "While the catheter is in place, I'll palpate the bladder with my dominant hand." B. "I should hold the catheter securely throughout drainage." C. "When removing the catheter, I should withdraw it quickly." D. "I should take the specimen with me and label it at the nurse's station."

45 mL Rationale: The total volume of breast milk or formula to be prepared should equal 4 hours' worth of feeding and the priming volume. For this infant 4 hours' worth of breast milk is 40 ml plus the 5 ml priming volume equals 45 ml. The 60-ml and 80-ml volumes exceed the recommended 4-hour volume. The 20-ml volume is less than the recommended volume.

The nurse is to administer a continuous drip of breast milk to an infant at 10 ml/hr via a syringe pump, as ordered. The priming volume for the selected tubing is 5 ml. How much breast milk should the nurse prepare? A. 25 ml B. 45 ml C. 65 ml D. 85 ml

Pour warm water over the child's perineum.

The nurse removed an indwelling catheter 7 hours ago. The child has not yet voided. What would be the first action taken by the nurse? A. Notify the practitioner. B. Scan the bladder for retained urine. C. Encourage the child to drink more fluids. D. Reinsert the indwelling catheter.

"The indwelling urinary catheter will be removed before the suprapubic catheter When the child has both a suprapubic and an indwelling catheter, the indwelling catheter is removed first. This is done to ensure that the suprapubic catheter is draining properly. The suprapubic catheter remains in longer than the indwelling catheter, particularly when bloody drainage is expected. The suprapubic catheter is maintained until appropriate healing has occurred and the child has an alternate means of accomplishing urinary drainage. Both catheters will not remain in the bladder at the same time, nor will both catheters be removed at the same time.

The parent of a 4-year-old child with both a suprapubic and an indwelling urinary catheter is receiving instruction on the catheter. What statement shows the parent understands the instructions? A. "My child will have both a suprapubic and an indwelling catheter until leaving for home." B. "The indwelling urinary catheter will be removed before the suprapubic catheter." C. "The suprapubic catheter will be removed before the indwelling urinary catheter." D. "Both catheters will be removed at the same time in a couple of days before discharge."

Tape the catheter to the lower abdominal wall. The catheter should be taped to the lower abdominal wall rather than the inner thigh to decrease stricture formation caused by pressure on the posterior urethra. The lower abdomen site is preferred for long-term use of catheters for males as it reduces the tissue damage to the urethra. Taping over the scrotal sac may injure this delicate tissue.

To avoid dislodging the catheter on a male child, the nurse secures the catheter. Which of the following best describes how this should be done? A. Tape the catheter to the lower abdominal wall. B. Tape the catheter over the scrotal sac. C. Tape the catheter to the inner thigh. D. Tape the catheter to the outer thigh.

Drink more fluids. The suprapubic catheter can cause bladder spasms and cramps. These symptoms can be reduced with increased hydration, analgesia, antispasmodic medications, and a warm compress on the bladder. Voiding more frequently empties the bladder of liquids but may cause more spasms or cramps. Placing an ice pack on the bladder would tighten the muscles and increase the spasms or cramps.

To decrease bladder spasms and cramps after suprapubic catheter placement, the child should be told to do what? A. Void frequently. B. Decrease fluid intake. C. Place an ice pack on the bladder. D. Drink more fluids.

4 hours Rationale: Each formula type exposed to room temperature has a recommended hang time for enteral feedings. Human breast milk has a 4-hour hang time. Sterile formulas in an open system for hospital administration have an 8-hour hang time. Sterile formulas in an open system for home administration have a 12-hour hang time. Sterile formulas in a closed system can have a hang time of 24 to 48 hours based on the product.

What is the recommended hang time for human breast milk being given via enteral feeding? A. 4 hours B. 8 hours C. 12 hours D. 24 hours

Inserting the airway directly, using a tongue depressor

What is the safe and recommended technique for inserting an OP airway in a patient? A. Inserting the airway directly, using a tongue depressor B. Inserting the airway upside down and rotating it into place C. Inserting the airway sideways and rotating it into place D. Using a laryngoscope to view the patient's airway during insertion

Flange

What part of the OP airway is most important when aligning the airway with the patient's face? A. Body B. Flange C. Tip D. Channel

The flange of the OP airway should be at the corner of the mouth. Rationale: Although the correct size OP airway is, in part, determined by the patient's size, the measurement should be done by placing the OP airway along the cheek from the corner of the mouth to the angle of the jaw. If the OP airway is too short, it may push the tongue posteriorly, leading to an obstruction; if the OP airway is too long, it may hit the epiglottis and obstruct the larynx.

What should be considered when selecting the correct size OP airway for a patient? A. The length of the airway is determined based on the patient's weight. B. If the OP airway is too short, it will hit the epiglottis and obstruct the larynx. C. If the OP airway is too long, it will push the tongue posteriorly. D. The flange of the OP airway should be at the corner of the mouth.

B. The distance from the tip of the nose to the tragus of the ear

What should the nurse measure to determine the appropriate-size NP airway for a 1-year-old patient? A. The distance from the corner of the mouth to the angle of the jaw B. The distance from the tip of the nose to the tragus of the ear C. The distance from the middle of the mouth to the tragus of the ear D. The distance from the tip of nose to the angle of the jaw

70 mm or size 2

What size OP airway should the nurse prepare for insertion for a 4-year-old patient? A. 60 mm or size 1 B. 50 mm or size 0 C. 80 mm or size 3 D. 70 mm or size 2

It ensures that your child's stomach remains empty." A gastric decompression tube is placed for removal of air or fluid from the stomach. Medications and nutrition are not administered through the NG tube during decompression when the primary function is evacuation of air or fluid from the stomach. Gastric decompression is not for irrigation.

When educating the family of a child with an NG tube, how should the nurse describe the purpose of a gastric decompression tube? A. "It provides a route for administration of medications to your child." B. "It ensures that your child's stomach remains empty." C. "It provides a route for nutrition to your child." D. "It provides a mechanism to irrigate your child's stomach."

Pressure areas along the lips, tongue, and roof of the mouth Rationale: An OP airway has the potential to cause significant ulcerations or trauma to the lips, tongue, and roof of the mouth. Potential pressure areas should be assessed frequently. The use of a bite block should not change the volume of secretions. Because the OP airway is being used as a bite block and not as an airway, there should be no need to place an NP airway. Correct sizing of the airway is determined when the airway is placed; an incorrect size airway should not be left in place.

When using an OP airway as a bite block for an endotracheal tube, what should the nurse assess frequently? A. Pressure areas along the lips, tongue, and roof of the mouth B. Copious secretions that prevent the tape from adhering to the patient's skin C. The need to change an OP airway to an NP airway D. The appropriateness of the airway size, depending on the patient's age

Clear the tube with water after the administration of each medication. Rationale: Flushing the feeding tube with purified or sterile water after administering medications is the best method to prevent clogging caused by administration of viscous medications or undissolved medications in powder form. Medications should not be mixed together or in the formula unless approved by a pharmacist because they may interact with each other or form a precipitate, altering the therapeutic effect of the medication and clogging the tube. Enteric-coated tablets are time-released medications; if they are crushed, the therapeutic effect of the medication will be negated.

Which strategy is the best for preventing medications from clogging the feeding tube? A. Crush enteric-coated tablets or capsules to a fine powder and use a water flush. B. Mix medications with the formula and administer it slowly. C. Administer medications together followed by a water flush. D. Clear the tube with water after the administration of each medication.

Instill warm water. Rationale: The nurse should first instill warm water into the EAD using a 30- or 60-ml syringe (a smaller syringe may be used with small children) and apply a gentle back-and-forth motion with the plunger. If the water flush does not resolve the clog, the nurse can try a pancreatic enzyme solution, an enzyme-containing unclogging kit, or a mechanical unclogging device. Three percent sodium chloride solution is not useful and may cause hypernatremia. Injecting air risks rupture of the tube and painful gas.

While attempting to administer a medication to a patient through a feeding tube, the nurse observes that the tube is clogged. What should the nurse do first to try to unclog the tube? A. Instill warm water. B. Instill a pancreatic enzyme solution. C. Instill warmed 3% sodium chloride solution. D. Inject air with a 20-ml syringe.

Anchor the IV tubing to prevent further kinks or obstructions. Rationale: Anchoring the tubing to prevent further kinks would be the first course of action. The practitioner should be notified and an order received prior to increasing the infusion rate. Changing the tubing and adding an IV house have no benefit in this instance. Starting an additional peripheral VAD is unnecessary.

While doing bedside report to the oncoming shift, the outgoing nurse reports that there have been some issues with the peripheral VAD. The outgoing nurse turned the fluids off and encouraged oral intake. The patient slept overnight and is now behind on intake. The oncoming nurse flushes the IV line and notes that the end of the T-connector is kinked. What would be the first course of action? A. Double the ordered IV infusion rate to make up the deficit. B. Anchor the IV tubing to prevent further kinks or obstructions. C. Keep the peripheral VAD in place and start another one. D. Change the IV tubing and add an IV house to protect the insertion site.

Using the treatment room keeps the child's bed a safe space. Rationale: All of these statements may be true regarding the treatment room, but the reason a treatment room is preferred is that is protects the child's bed as safe space where painful or frightening procedures are not performed.

Why is a treatment room the preferred place for removal of a urinary catheter? A. The treatment room is cleaner than the child's room. B. Using the treatment room keeps the child's bed a safe space. C. All distraction tools and supplies can be stored in the treatment room. D. Privacy can be more easily provided in the treatment room.