Title WORKBOOK - FUNDA (KEY) ✅

D. Injecting air into the tube with a syringe and listening for rush of air. 35. Which of the following is the most appropriate initial action of the nurse when the client vomits 200 ml after the nasogastric tube insertion? A. Change the suction applied to the nasogastric tube from intermittent to continuous. B. Advance the nasogastric tube 2”(5cm). C. Replace a nasogastric contents with a large one. D. Ensure that the head of the patient is elevated 36. Which among the following methods would be most helpful to the nurse when measuring the length of the nasogastric tube to be inserted to the client? A. Center of forehead to top of nose to end of sternum B. Tip of nose to tip of earlobe to end of sternum C. Lips to tip of ear to just below the umbilicus D. Tip of ear to midway between end of sternum and umbilicus 37. How should the nurse check the proper placement of the nasogatric tube after insertion? A. The patient no longer complains of pain or nausea B. 30 ml of normal saline can be injected with ease C. Bubbles occur when the tube is submerged into water D. Gastric contents are aspirated with cone tipped syringe 38. Another client is receiving an enteral feeding through the open system container. A knowledgeable nurse knows that the difference between an open and closed system enteral feeding is that; A. An open system uses an open top container uses a syringe for administration B. An open system uses an open top container or a syringe for administration and a closed system consists of prefilled container that is spiked with enteral access device. C. Closed system uses prefilled comtainer that can hang for 24 hours if sterile technique is used and open system should have no more than 24 hours of formula feedings poured at one time D. Open system uses prefilled container and closed system uses open top container 39. During the report, the nurse indicates that the client’s NG tube quit draining over the last hour. Prior to that, it was draining 100 ml of fluid q 2 hr. which plan would best assist this client? A. Anchor a new NG tube B. Reposition the tube to promote drainage C. Order a chest X-ray to determine the placement D. Force 50 ml of normal saline down the tube 40. Which of the following actions of the nurse would indicate a need for further teaching about the methods used to safely ensure proper NGT placement? A. When confirming tube placement, place the tube’s end in a container of water B. Use tongue blade and penlight to examine mouth and throat for signs of a coiled section of tubing C. Stop advancing tube when tape mark reaches the client’s nostril. D. Inject 10 cc of air into tube. At the same time, auscultated for air sounds with stethoscope placed over the epigastric region. 41. The nurse is to remove the client’s nasogastric tube. Which of the following is the correct sequence of actions the nurse should follow? 1. Assist client into semi-Fowler’s position 2. Ask the client to hold her breath 3. Assess bowel function by auscultation for peristalsis 4. Flush tube with 10 ml of normal saline 5. Withdraw the tube gently and steadily 6. Monitor client for nausea and vomiting A. 5, 3, 1, 4, 2, 6 B. 4, 2, 1, 6, 3, 5 C. 3, 1, 4, 2, 5, 6 D. 1, 3, 2, 4, 6, 5 Situation: A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube. This is indicated for clients who need long term airway support. 42. The nurse is caring for a 45 year old male client diagnosed with throat cancer. He was tracheostomized two days ago and the nurse needs to clean his tracheostomy tube. Which among the following parts of the tracheostomy tube can the nurse remove for cleaning? A. Outer cannula B. Inner cannula C. Single-lumen tube D. Double-lumen tube 43. As the nurse of a client with tracheostomy tube, which among the following safety precaution should you make? A. Keep a crash cart in the room B. Be prepared to put him on a ventilator C. Keep curved hemostat at the bedside D. Be prepared to remove the tube 44. What is the purpose of keeping an obturator on the bedside of a client with tracheostomy tube? A. To facilitate insertion of the outer cannula B. To secure the ties of the tube C. To be kept by the client D. To be used to make an opening for the tube 45. To remove crusty secretion on the incision site and tube flange of the client’s tracheostomy tube, the nurse should soak the sterile applicator in what solution? A. Ethyl alcohol B. Isopropyl alcohol C. Hydrogen peroxide (Full strength) D. Hydrogen peroxide ( half-strength solution mixed with sterile normal saline) 46. A nurse in the medical-surgical unit noticed that the adult clients who need long term airway support have a tracheostomy tube with cuffs. The nurse is aware that the main purpose of a tracheostomy tube with inflatable cuff is; TOP RANK REVIEW ACADEMY, INC. Page 4 | 9