chapter 22

Question 1

How do you suction a tracheostomy catheter?

Answer 1

A. Insert catheter without suction
B. limit suctioning to 10-15 seconds.
C. Gently withdraw suction if patient is coughing.
D. Hyperoxengate before suctioning.
E. apply suction, twist and rotate while removing catheter.

Question 2

what is the effect of heat treatments?

Answer 2

Increases blood flow or improvement of circulation.

Question 3

steps for Foley catheter insertion?

Answer 3

1. check the balloon by injection NORMAL SALINE or STERILE water - before catheter injection.
2. Insert 2-4” for female and 6-7” for male
3. when you see urine - insert 1-2 inches further.

Question 4

when you see urine return after insertion of a Foley catheter, what do you do next?

Answer 4

Advance the catheter another inch or two.

Question 5

How do you remove a Foley catheter?

Answer 5

deflate the balloon.

Question 6

After removal of Foley catheter, what do you asses?

Answer 6

urinary retention.

Question 7

how do you prepare a patient for MRI?

Answer 7

-Check for allergy to iodine or shell fish;; if the client has metals inside the body.

Question 8

the category of patients that would require an indwelling catheter-

Answer 8

Patients in labor; UTI; enlarge prostate, urinary retention.

Question 9

what is the early sign of hypoxia?

Answer 9

restlessness.

Question 10

what is involved in a routine catheter care—

Answer 10

• cleaning the first 2–4 inches of the catheter with soap and water every shift.

Question 11

ileostomy drains wha type of stool?

Answer 11

semi- liquid

Question 12

Guaic test is ordered for what purpose?

Answer 12

GI Bleed.

Question 13

explain paracentesis–

Answer 13

a needle is used to aspirate fluid from the peritoneal cavity.

Question 14

how do you measure the tube for nasogastric insertion—

Answer 14

Tip of the nose to the earlobe to the xiphoid process.

Question 15

what tube is used for gastric decompression in patient diagnosed with bowel obstruction?

Answer 15

Salem sump.

Question 16

How do you direct the solution while performing eye irrigation and what is the rationale–

Answer 16

Direct the solution along conjunctive from inner to outer cants.
Rational- prevent contaminants being absorbed by nasolacrimal duct and to protect the nasolacrimal ducts.

Question 17

what are the safety measures when administering oxygen-

Answer 17

• No smoking sign on the door.
• Use cotton blankets rather than wool blankets.
• Do not use wool carpeting.
• Avoid clothing that is not fire resistant.
• Avoid petroleum products- like petroleum jelly.
• Avoid electrical appliances - heating pads, razors, ETC.

Question 18

What are the normal findings when assessing stoma?

Answer 18

• Stoma should be moist and pinkish red or reddish pink in color.
• It should protrude from the abdomen.
• Stool should come out from the stoma.

Question 19

What is the abnormal finding of the stoma?

Answer 19

• Stoma appears gray.

Question 20

What can increase the risk of acquiring UTI on a patient with indwelling catheter-

Answer 20

Hanging the bag on the side rails.

Question 21

How do you position on a drainage bag correctly?

Answer 21

• Keep the drainage bag below the bladder level- to maintain a constant downward flow of urine.

Question 22

What is the position for administering enema?

Answer 22

Left sim’s position.

Question 23

what would you report in a patient using a partial non breather mask -

Answer 23

bag totally collapses during inspiration.

Question 24

What are the normal assessment findings on a patient with a face mask?

Answer 24

• Mask go over the bridge of the nose and covers the mouth and nose.
• Strap should be snug around the head.
• Normal to have moisture accumulate inside the mask.
• ** Delivers 6-10 L/min.

Question 25

What are the reasons for suctioning-

Answer 25

• Cyanosis
• Breath sounds are wet or noisy
• Ineffective cough
• Restlessness

Question 26

Inserting a indwelling catheter is a sterile or non sterile procedure-

Answer 26

Sterile

Question 27

how do you administer an enema?

Answer 27

• Left Sim’s position
• Hang container 12-18 inches above level of anus
• if patient c/o cramping- stop the flow and restart when cramping goes away.

Question 28

nursing interventions for ileostomy and colostomy?

Answer 28

• Stoma should be moist and pinkish red or redish pink in color.
• if grey appears - report.
• Inspect color, size and condition of the stoma.
• Apply a skin barrier substance to excoriated skin as ordered to protect the peristomal skin.
• Avoid using alcohol around stoma- Peroxide irritates tissue.
• Clean around stoma with mild soap and water.
• Use dietary measures to control odor.

Question 29

Type of enema used for fecal impaction?

Answer 29

Oil retention.

Question 30

What are the effects of cold therapy?

Answer 30

Causes vasoconstriction .

Decrease swelling, decrease bleeding and reduce pain.

Question 31

Nursing intervention when caring for a patient with NG tube?

Answer 31

• Mark where the use exits the nose.
• Verify placement before feeding.
  1. injector into the tube while listening to the stomach with a stethoscope.
  2. Aspirate gastric contents.

Secure tube to the nose with a tape or nose guard (athletes use this)
Fasten end of the tube to the gown by looping rubber band around the tube in a slip knot.
Pin rubber band to gown.

Question 32

What is the minimum urine output in an hour?

Answer 32

30 cc/hr.

Question 33

Nursing interventions when caring for a patient on nasal cannula?

Answer 33

Check for irritation behind the hear.
Check for pressure over the cheecks - q 2 hrs.
Place nasal prong into each nostrils - facing down wards.
Apply water soluble lubricant to nares as needed.

Question 34

an effective way for clearing secretions?

Answer 34

Deep breathing and coughing

Question 35

what is the advance of venture mask?

Answer 35

give a precise concentration of oxygen.

Question 36

what are the uses of condom catheter?

Answer 36

to prevent skin breakdown for an incontinent male patent.
monitor urine out put.
for a male client having frequent urination.

Question 37

early skin of hypoxia?

Answer 37

restlessness.