Exam (elaborations)
Nur155 nur 155 exam 2 latest 2024/ 2025 foundations of nursing galen
- Course
- NUR 155 (NUR155)
- Institution
- Galen College Of Nursing
Nur155 nur 155 exam 2 latest 2024/ 2025 foundations of nursing galen
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Fundamentals of Nursing Exam 2Study online at https://quizlet.com/_g0yh9w
d
Rationale: During the insertion of the naso-
gastric tube, if the client experiences diffi-
1. 1) The nurse is inserting a culty breathing or any respiratory distress,
nasogastric tube in an adult
client. During the procedure,
the client begins to cough and
has difficulty breathing. What is withdraw the tube slightly, stop the tube
the most appropriate action? advancement, and wait until the distress
a. Insert the tube quickly. subsides. It is not necessary to notify the
b. Notify the health care HCP immediately or remove the tube com-
provider immediately. pletely. Quick inserting the tube is not an
c. Remove the tube and rein- appropriate action because, in this situa-
sert it when the respiratory dis- tion, it is likely that the tube has entered the
tress subsides. bronchus.
d. Pull back on the tube and
wait until the respiratory dis-
tress subsides.
2. 2) The nurse receives a tele- a
phone call from the post anes- Rationale: The first action of the nurse is to
thesia care unit stating that assess the patency of the airway and res-
a client is being transferred to the piratory function. If the airway is not patent,
surgical unit. The nurse the nurse must take immediate measures
plans to take which action first on for the survival of the client. The nurse then
arrival of the client? takes vital signs followed by checking the
a. Assess the patency of the dressing and the tubes or drains. The other
airway nursing actions should be performed after
b. Check tubes or drains for pa- a patent airway has been established.
tency
c. Check the dressing to assess
for bleeding
d. Assess the vital signs
to compare with preoperative
measurements
3. 3) The nurse is administering with a fecal impaction. Before
a cleansing enema to a client administering the enema, the
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
a enema, the client is placed in a left Sims'
Rationale: For administering an position so that the enema solution can flow
by gravity
nurse should place the client in in the natural direction of the colon. The
which position?
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
a. Left Sims' position head of the bed is not elevated in the Sims'
b. Right Sims' position position.
c. On the left side of the body,
with the head of the bed elevat-
ed 45 degrees
d. On the right side of the body,
with the head of the bed elevat-
ed 45 degrees.
4. 4) The nurse is preparing to in- c
sert a nasogastric tube into a Rationale: During insertion of a nasogastric
client. The nurse should place tube, the client is placed in a sitting or high
the client in which position for Fowler's position to facilitate insertions of
insertion? the tube and reduce the risk of pulmonary
a. Right side aspiration if the client should vomit. The
b. Low Fowler's right side, and low Fowler's and supine po-
c. High fowler's sitions place the client at risk for aspiration;
d. Supine with the head flat in addition, these positions do not facilitate
insertion of the tube.
5. 5) The nurse is preparing to a, b, c, e
administer medication using a Rationale: By aspirating stomach contents,
client's nasogastric tube. What the residual volume can be determined,
actions should the nurse take and the pH checked. A pH less than 3.5 ver-
before administering the med- ifies gastric placement. The suction should
ication? Select all that apply. be turned off before the tubing is discon-
a. Check the residual volume nected to check for residual volume; in ad-
b. Aspirate the stomach con- dition, suction should remain off for 30 to
tents 60 minutes following medication adminis-
c. Turn off the suction to the tration to allow for medication absorption.
nasogastric tube There is no need to remove the tube and
d. Remove the tube and place it place it in the other nostril in order to ad-
in the other nostril minister a feeding; in fact, this is an invasive
e. Test the stomach contents procedure and is unnecessary.
for a pH indicating acidity
6. 6) The nurse is preparing to ad- c
minister medication through a Rationale: If the client has a nasogas-
nasogastric tube that is con- tric tube connected to suction, the nurse
, Fundamentals of Nursing Exam 2
Study online at https://quizlet.com/_g0yh9w
nected to suction. To adminis- should wait 30 to 60 minutes before recon-
ter the medication, the nurse necting the tube to suction apparatus to
should take which action? allow adequate time for medication absorp-
a. Position the client supine tion. The client should not be placed in the
to assist in medication absorp- tion supine position because of the risk for aspi-
b. Aspirate the nasogastric tube ration. Aspirating the nasogastric tube will
after medication adminis- remove the medication just administered.
tration to maintain patency. Low intermittent suction also will remove
c. Clamp the nasogastric tube the medication just administered.
for 30 to 60 minutes following
administration of the medica-
tion
d. Change the suction setting to
low intermittent suction for 30
minutes after medication ad-
ministration
7. 7) The nurse is assessing for d
correct placement of a naso- Rationale: If the nasogastric tube is in the
gastric tube. The nurse aspi- stomach, the pH of the contents will be
rates the stomach contents, acidic. Gastric aspirates have acidic pH val-
checks the gastric pH, and ues and should be 3.5 or lower. A pH of 7.35
notes a pH of 7.35, Based on indicates a neutral pH, which may indicate
this information, which action that the tube is no longer in the stomach.
should the nurse take at this Based on this information, the nurse should
time? call the HCP to request a chest xray to
a. Retest the pH using another determine if placement is accurate. Retest-
strip ing the pH using another test strip is un-
b. Document that the nasogas- necessary and checking for placement by
tric tube is in the correct place auscultating for air injected into the tube is
c. Check for placement by aus- not a definitive method of checking for tube
cultating for air injected into placement. The nurse should not document
the tube that the tube is in the correct place because
d. Call the health care provider to the data indicates this may not be the case.
request a prescription for a
chest radiograph (xray)
8.
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