In what position would the nurse place the client prior to removing a nasogastric tube quizlet?
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Which nursing assessment takes priority when administering an enema to a client? Show a) Anxiety dizziness The nurse is getting ready to administer a large-volume cleansing enema to a client undergoing bowel surgery. Which action should the nurse take prior to the procedure? a) Cool the solution to facilitate easy
flow. Lubricate the tip of the rectal tube for easy insertion. The nurse is administering a large-volume enema to treat a client's constipation. After checking the enema device for defects, what should the nurse do next? a) Hang the enema bag on the IV pole. Add the enema solution and any additives to the enema bag. The nurse is inserting an enema tube into the anus of the client to treat constipation. How should the nurse insert the tube? a) Insert tube 1 to 2 in (2.5 to 5 cm) and angle toward the naval. Insert tube 3 to 4 in (7.5 to 10 cm) and angle toward the naval. The nurse is administering a large-volume cleansing enema. After stopping the enema, which instructions should the nurse provide if the client reports severe pain and bloating? a) Breathe in short, shallow breaths. Breathe out in short, panting breaths. Place in order the steps the nurse should take if a client reports cramping and bloating during enema administration. Use all options. 1. Administer the enema slowly at a height less than 18 in (0.5 m) above the client. 2.term-4 Stop administration if the client reports severe cramping and bloating. 3.Encourage the client to take short, panting breaths until the cramping subsides. 4. Discontinue the procedure and notify health care provider if pain occurs. Stop administration if the client reports severe
cramping and bloating. The nurse is preparing a client to administer a small-volume cleansing enema. In what position would the nurse place the client for this procedure? a) lying on the right side with
the head of the bed slightly raised lying on the left side with the bed flat and the back of the client facing the nurse A nurse is administering a small-volume enema to a client to
relieve fecal impaction. After initiating this action, the client reports nausea and lightheadedness. The nurse also notes a decrease in the client's heart rate. What should the nurse do first? Stop the procedure and monitor client's heart rate. The nurse has finished installing a small-volume cleansing enema into a client. What instructions would the nurse give the client following the installation? a) "Hold the solution in for 15 to 20 minutes." "Hold the solution in until the need to defecate is strong." The client asks to help express the small-volume enema solution. Which instructions by the nurse will best facilitate instilling the enema solution completely? a) "Allow gravity to empty the solution from the enema bag then slide the clamp before removal." "Roll the bag toward the buttocks and then keep it rolled while removing it from the rectum." The nurse is teaching a client how to empty an ostomy appliance. How often would the nurse recommend the appliance be emptied? a) Daily when bag is one-third to one-half full The nurse is emptying an ostomy appliance for a client on bed rest. In what position would the nurse place the client for this procedure? a) prone sitting The nurse is teaching a client about emptying an ostomy appliance. How would the nurse instruct the client to hold the appliance when removing the closing clamp? a) Downward upward After removing the closing clamp on a colostomy appliance, what would be the nurse's next step before emptying the appliance? a) Hold the bag open with the nondominant hand. Fold the end of the pouch upward, like a cuff. The nurse is preparing to empty an open-ended colostomy pouch. Place in order the steps the nurse would take. Use all options. 1. Uncuff the edge of the pouch. 2. Wipe the lower 2 in (5 cm) of the pouch with toilet tissue. 3. Fold the end of the pouch upward like a cuff. 4. Apply the clamp. 5. Empty the contents into a measuring device. Fold the end of the pouch upward like a cuff. The nurse is monitoring a client with a colostomy and notices that the ostomy appliance is leaking. What would be the appropriate nursing action in this situation? a) Repair the appliance with tape. Change the appliance immediately. The nurse has taught a client how to change the ostomy bag. How would the clamp be placed to demonstrate that the client understood the directions? a) The clamp is straight and would be horizontal to the client's body. The curve of the clamp would follow the curve of the client's body. The nurse is assisting a client with changing an ostomy appliance. What is the best method of ensuring that the client has understood the procedure and is able to perform it independently? a) Ask the client to repeat each step as it is taught. After performing the first appliance change, observe the client performing the next change. The nurse is collecting supplies to change the ostomy appliance of a client who has an ileostomy following surgery for a tumor. What items would the nurse prepare to wash around the stoma? a) basin of
warm water basin of warm water The nurse is observing a client learning to change the ostomy appliance. Which action by the client would require the nurse to intervene? a) Client traces the same sized opening on the back of the new appliance. Client cuts the opening on the new bag 0.5 in (1.25 cm) larger than the stoma size. While changing the ostomy appliance of a client with a colostomy, the nurse finds significant bleeding from the area around the stoma. What would be the recommended nursing action after notifying the health care provider? a) Wash the area with soap and warm water, allow it to dry, and do not apply the new appliance. Gently pat the area dry and apply the new appliance when the skin is completely dry. When changing a client's ostomy appliance, the nurse finds that feces continue to flow from the stoma, making applying the new appliance difficult. What would be the recommended action when this occurs? a) Wait for the drainage to stop prior to applying the new appliance. Place a piece of gauze over the stoma to absorb the drainage. After measuring from the client's nostril to the ear lobe, how does the nurse continue to measure the length of the nasogastric (NG) tube to be inserted for a client? a) to the tenth intercostal space to the xiphoid process After inserting a nasogastric (NG) tube, what should the nurse do to ensure that the tube is properly placed in the client? a) Obtain an abdominal ultrasound. Test the pH of aspirated content. A nurse aspirates fluid through a client's nasogastric tube and checks the fluid for color and consistency. Which is a normal finding suggesting correct gastric placement of the tube? a) gray color with particles green color with particles Following insertion of a nasogastric tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take? a) Tape the tubing to the client's sleeve below shoulder level. Secure the tubing with a safety pin to the client's gown at shoulder level. Which documentation does the nurse complete after inserting a client's nasogastric (NG) tube? a) amount of time it took to complete the procedure measurement of the exposed tube The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what does the nurse do next? a) Insert the tube into the other nostril. Proceed with nasogastric tube placement. The nurse is preparing to irrigate a client's NG tube. Which would the nurse include when teaching the client about this procedure? a) "You may feel cold solution going down your throat, but it should not hurt." "You may feel cold solution going down your throat, but it should not hurt." The nurse is following the protocol for irrigating a client's nasogastric (NG) tube. Before attaching the syringe to irrigate the tube, which action would be most important for the nurse to do? a) Check tube placement. Check tube placement. In what position would the nurse hold the syringe when instilling irrigation solution into the nasogastric (NG) tube? a) Downward at a 90-degree angle. Downward at a 90-degree angle. The nurse has completed irrigation of a nasogastric tube connected to suction. Which step would the nurse perform following the injection of irrigation solution into a client's nasogastric tube? a) Inject 30 mL of sterile water into the tube. Connect the unclamped NG tube back to the suction unit. When irrigating a nasogastric tube, the nurse does not get a return after instilling irrigation solution and reconnecting the tube back to the suction unit. What would be the nurse's next step in this situation? a) Instill 30 mL of irrigation solution into the tube and aspirate again. Instill 20 mL of air into the tube and aspirate again. The nurse is not successful in attempting to irrigate a nasogastric tube. The nurse repositions the client and tries to flush the tube with air and water multiple times without success. What action does the nurse take next? a) Document implemented interventions. Notify the health care provider. The nurse is irrigating a nasogastric (NG) tube connected to suction for a client undergoing gastric decompression and meets resistance after attaching the irrigation syringe to the NG tube. Which would be most appropriate for the nurse to do first? a) Use 50 mL air instead of irrigation solution. Reposition the client and try again. The nurse is monitoring a client who had a nasogastric (NG) tube placed postoperatively after abdominal surgery. Which criterion would the nurse use to determine that the tube could be removed? a) Passage of flatus. Passage of flatus. In what position would the nurse place the client prior to removing a nasogastric tube? a) Sitting on the side of the bed. In an upright position with the bedrail nearest the nurse down. The health care provider has written a prescription for a client's nasogastric (NG) tube to be removed. Which would the nurse do first? a) Take off the adhesive tape from the client's nose. Discontinue the suction. Which would be most appropriate for the nurse to do when removing a nasogastric (NG) tube? a) Ask the client to take a deep breath and pull out the tube quickly and carefully. Ask the client to take a deep breath and pull out the tube quickly and carefully. Following the removal of a nasogastric NG tube, the nurse should monitor the client for which possible adverse reaction? a) Decreased fluid output. Gastric distention. Which of the following actions by the nurse is appropriate when inserting a nasogastric tube?1)Place the client in high Fowler's position. 2)Measure the intended length to insert the NG tube. 3)Lubricate the tube tip with water-soluble lubricant. 4)Direct the tube upward and backward along the floor of the nose.
In what position would the nurse hold the syringe when instilling irrigation solution into the nasogastric NG tube?In what position would the nurse hold the syringe when instilling irrigation solution into the nasogastric (NG) tube? Downward at a 90-degree angle. The nurse meets resistance when irrigating a nasogastric tube.
What should the nurse do to verify nasogastric NG tube placement select all that apply?Nurses can verify the placement of the tube by performing two of the following methods: ask the patient to hum or talk ( coughing or choking means the tube is properly placed); use an irrigation syringe to aspire gastric contents; chest X-ray; lower the open end of the NG tube into a cup of water ( bubbles indicate ...
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