HEALTH PROMOTION & MAINTAINENCE Flashcards
What is the purpose of a nasogastric tube?
Decompress the Stomach by removing fluids or gas
Decrease the risk of aspiration
Administer Medications to people who cannot swallow
Provide nutrition by acting as a temporary feeding route
Irrigate the stomach and remove harsh chemicals and toxins, such as poisoning
How do ensure that a Nasogastric tube in place? What do you do if it placed in the lungs?
Obtain a Xray to ensure proper placement, to ensure placement is still correct, auscultate under the xiphoid process and inject air into the stomach (you will hear it).
If the tube is in the lungs, remove the tubing. duh
How often should an NG tube be changed? A/ 12 hours B/ 24 Hours C/ 36 Hours D/ 72 Hours
B/ 24 hours
Your patient has an NG tube and requires feeding. As per protocol, you withdraw fluid from the stomach through the tube. You withdraw 123cc of fluid. What should you do next?
A/ Raise the head of the bed and administer the feeding
B/ Withhold the feeding
C/ Flush the NG tube with 25cc of fluid and wait 15 minutes before feeding
D/ Test the pH of the fluid, readminister the fluid and feed the patient
B/ Withhold the feeding.
If the residual volume of gastric juices exceeds 100cc of fluid, feeding is to be withheld as increasing the amount of substances in their stomach increases the risk of aspiration
You feed your patient through their NG tube and they begin to feel nauseated 10 minutes later and throw up. Which of the following factors increases vomiting through NG tube feeding? Select all that apply. A/ Air in Tubing B/ Slow infusion of feeding C/ Administration of cold food D/ Allowing the feeding bag to go empty E/ Flushing with NS after feeding
A/ Air
C/ Cold food
D/ Empty bag
What should you do when your patient begins the feel nauseated and vomits after eating from an NG tube?
Elevate the head of the bed
Administer food that is room temp
Give antiemetics
Why would an Orotracheal Tube be indicated over a Nasotracheal tube?
Orotracheal tubes enable a larger diameter tube to be placed, decreasing the patient’s respiratory effort needed over a nasotracheal tube.
Why Would a nasotracheal tube be indicated over an Orotracheal tube?
Nasotracheal tubes are smaller and cannot be bitten or moved by a tongue like the Orotracheal tube.
What must be done when removing an endotracheal tube?
- Hyperoxygenate the patient
- Semi-Fowler’s Position
- Deflate the cuff and have the patient inhale and at the peak of their inspiration, remove the tubing while suctioning
- Instruct the patient to cough and deep breathe after the tubing is removed
- Apply O2 as prescribed (if needed)
Which of the following are interventions for Tracheostomy tubes? Select All that Apply A/ Monitor ECG B/ Encourage deep breathing and coughing C/ Hyperoxygenate while suctioning D/ Administer Humidified oxygen E/ Ensure reverse Trendelenburg Position F/ Monitor Cuff Pressure
B/ Breathing and coughing
C/ Hyperoxygenate
D/ Humidified Oxygen
F/ Monitor Cuff Pressure
You have a patient with a chest tube, you walk over to assess her and notice bubbling in their suction control chamber. What should you do next?
A/ Clamp the system, Check the patient for bleeding and notify the HCP
B/ Check the patient’s respiratory status, Pulse oximetry, and blood pressure
C/ Nothing, this is to be expected
D/ Clamp the system and replace the Collection Chamber
C/ Nothing.
Bubbling in the suction control chamber is normal and indicated proper suctioning.
Excessive constant Bubbling in the Water-seal chamber indicates an air leak in the system
Your patient has a pneumothorax and is on a chest tube. You come in hourly to do your checks on your patient and you notice in the past hour the patient’s drainage is 95cc. What is your next course of action?
A/ Notify the HCP
B/ Ensure a collection system is still a closed unit
C/ Clamp the hosing and check their respiratory status
D/ Do nothing, as this is normal.
A/ Notify the HCP
NEVER CLAMP
This is an excessive amount for the past hour and could indicate many problems. Notify HCP ASAP.
The nurse in an outpatient facility is supervising a student nurse giving flu vaccines. The nurse should question the administration of the vaccine to which of the following clients?
A/ 45 year old male allergic to shellfish
B/ 60 year old woman who states she has a sore throat
C/ 66 year old woman who lives in a group home
D/ 70 year old male with congestive heart failure
B/ 60 year old woman who states she has a sore throat
The vaccine is contraindicated in people with acute respiratory infections or diseases.
Shellfish does not lead to a contraindication, allergy to eggs would be contraindicated.
A 2 month old infant is brought in for a well-baby visit. At the initial assessment, the nurse notes congenital subluxation of the left hip. The nurse known the symptoms of congenital hip dislocation include:
A/ Lengthening of the limb on the affected side
B/ Deformities of the foot and ankle
C/ Asymmetry of the gluteal and thigh folds
D/ Plantar flexion of the foot
C/ Asymmetry of the gluteal and thigh folds
Subluxation is the most common type of hip dislocation. The head of the femur remains in contact with the acetabulum but is partially displaced. Signs and symptoms include: Uneven gluteal folds Limited abduction of the hip Shortened Femur on affected side Ortolani's Sign (Click sound)
A client has a fractured tibia and a cast is applied. When caring for the client, the nurse should:
A/ Cover the cast with plastic wrap until it dries
B/ Assist the client with weight bearing when they ambulate
C/ Elevate the affected leg above the level of the heart
D/ Insert a finger inside the cast to check for skin abrasions
C/ Elevate the affected leg above the level of the heart
Elevation will help the leg edema to subside. Plastic wrap holds moisture in and will interfere with cast drying. Full weight bearing is not indicated until prescribed by the HCP. Nothing should be inserted into the cast as this can cause tissue injury.
