Fundamentals of Nursing Exam 2
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1. 1) The nurse is inserting a d
nasogastric tube in an adult Rationale: During the insertion of the naso-
client. During the procedure, gastric tube, if the client experiences diffi-
the client begins to cough and culty breathing or any respiratory distress,
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 piratory function. If the airway is not patent,
to the surgical unit. The nurse the nurse must take immediate measures
plans to take which action first for the survival of the client. The nurse then
on 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 a
a cleansing enema to a client Rationale: For administering an enema, the
with a fecal impaction. Before client is placed in a left Sims' position so
administering the enema, the 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
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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
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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- supine position because of the risk for aspi-
tion ration. Aspirating the nasogastric tube will
b. Aspirate the nasogastric remove the medication just administered.
tube after medication adminis- Low intermittent suction also will remove
tration to maintain patency. the medication just administered.
c. Clamp the nasogastric tube
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 the data indicates this may not be the case.
to request a prescription for a
chest radiograph (xray)
8.
, Fundamentals of Nursing Exam 2
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8) The registered nurse is c
preparing to insert a nasogas- Rationale: Measuring the length of a na-
tric tube in an adult client. To sogastric tube needed is done by placing
determine the accurate mea- the tube at the tip of the client's nose and
surement of the length of the extending the tube to the earlobe and then
tube to be inserted, the nurse down to the xiphoid process. The average
should take which action? length for an adult is about 22 to 26 inches
a. Mark the tube at 10 inches (56 to 66 cm). The remaining options iden-
(25.5 cm) tify incorrect procedures for measuring the
b. Mark the tube a 32 inches (81 length of the tube.
cm)
c. Place the tube at the tip of
the nose and measure by ex-
tending the tube to the earlobe
and then down to the xiphoid
process
d. Place the tube at the tip of
the nose and measure by ex-
tending the tube to the earlobe
and then down to the top of the
sternum
9. 9) The nurse inspects the color a
of the drainage from a naso- Rationale: For the first 12 hours after gas-
gastric tube on a postoperative tric surgery, the nasogastric tube drainage
client approximately 24 hours may be dark brown to dark red. Later, the
after gastric surgery. Which drainage should change to a light yellow-
finding indicates the need to ish-brown color. The presence of bile may
notify the health care provider cause a green-tinge. The HCP should be
(HCP)? notified if dark red drainage, a sign of hem-
a. Dark red drainage orrhage, is noted 24 hours postoperatively.
b. Dark brown drainage
c. Green-tinged drainage
d. Light yellowish-brown
drainage
10. 10) A nurse is assessing a pa- b, c, d
tient who has had diarrhea for Rationale: Prolonged diarrhea leads to de-
4 days. Which of the following hydration, expect the client to have an el-
