Fundamentals of Nursing Exam 2:

Fundamentals of Nursing Exam 2:

Questions & Answers

1) 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?

• Insert the tube quickly.
• Notify the health care provider immediately.
• Remove the tube and reinsert it when the respiratory distress subsides.
• Pull back on the tube and wait until the respiratory distress subsides.

(Ans- d

Rationale: During the insertion of the 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 HCP immediately or remove the tube completely. Quick inserting the tube is not an appropriate action because, in this situation, it is likely that the tube has entered the bronchus.

2) The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

• Assess the patency of the airway
• Check tubes or drains for patency
• Check the dressing to assess for bleeding
• Assess the vital signs to compare with preoperative measurements

(Ans- a

Rationale: The first action of the nurse is to assess the patency of the

airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains.The other nursing actions should be performed after a patent airway has been established.

3) 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
• Right Sims' position 1 / 4

• On the left side of the body, with the head of the bed elevated 45

degrees

• On the right side of the body, with the head of the bed elevated 45

degrees.(Ans- a

Rationale: For administering an enema, the client is placed in a left Sims'

position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

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

• Right side
• Low Fowler's
• High fowler's
• Supine with the head flat

(Ans- c

Rationale: During insertion of a nasogastric tube, the client is placed in a

sitting or high Fowler's position to facilitate insertions of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

5) The nurse is preparing to administer medication using a client's nasogastric tube. What actions should the nurse take before administering the medication? Select all that apply.

• Check the residual volume
• Aspirate the stomach contents
• Turn off the suction to the nasogastric tube
• Remove the tube and place it in the other nostril
• Test the stomach contents for a pH indicating acidity

(Ans- a, b, c, e

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 an invasive procedure and is unnecessary. 2 / 4

6) 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?

• Position the client supine to assist in medication absorption
• Aspirate the nasogastric tube after medication administration to maintain

patency.

• Clamp the nasogastric tube for 30 to 60 minutes following administration

of the medication

• Change the suction setting to low intermittent suction for 30 minutes after

medication administration (Ans- c

Rationale: If the client has a nasogastric tube connected to suction, the

nurse should wait 30 to 60 minutes before reconnecting the tube to 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.

7) The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35, Based on this information, which action should the nurse take at this time?

• Retest the pH using another strip
• Document that the nasogastric tube is in the correct place
• Check for placement by auscultating for air injected into the tube
• Call the health care provider to request a prescription for a chest

radiograph (Xray) (Ans- d

Rationale: If the nasogastric tube is in the stomach, the pH of the contents

will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the stomach. Based on this information, the nurse should call the HCP to request a chest xray to determine if placement is accurate.Retesting the pH using another test strip is unnecessary and checking for placement by auscultating for air injected into the tube is not a definitive method of checking for tube placement. The nurse should not document that the tube is in the correct place because the data indicates this may not be the case. 3 / 4

8) 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?

• Mark the tube at 10 inches (25.5 cm)
• Mark the tube a 32 inches (81 cm)
• 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

• 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 (Ans- c

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 (56 to 66 cm). The remaining options identify incorrect procedures for measuring the length of the tube.

9) The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)?

• Dark red drainage
• Dark brown drainage
• Green-tinged drainage
• Light yellowish-brown drainage

(Ans- a

Rationale: For the first 12 hours after gastric surgery, the nasogastric tube

drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green-tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

10) A nurse is assessing a patient who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply)

• Bradycardia
• Hypotension
• Elevated temperature
• Poor skin turgor
• Peripheral edema

(Ans- b, c, d

• / 4