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22 Cards in this Set
- Front
- Back
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The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to?
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Elevate the head of the bed to 45 degrees
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A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement:
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Checks the pH of the gastric contents
Compares exposed tube length with original measurement Visually assesses the color of the aspirate |
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The nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc. The priority nursing action is to?
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Reassess the residual gastric content in 1 hour
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The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is?
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Flush with 10 mL of water
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Hickman and Groshong are examples of which type of central venous access devices?
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Tunneled central catheters
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The nurse notes that the site of a client's peripheral IV is reddened, warm, painful and slightly swollen proximal to the insertion point. Based on this assessment what is the nurse seeing and what should she/he do first?
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Phlebitis, stop the IV infusion
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When assessing IV site for infiltration what should you look for?
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Drop in temp around site, local swelling at site, a damp dressing
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What size catheter gauge is use for IV therapy on older adults, children, stable postoperative clients?
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22-24 gauge
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What is the process for inserting an NG tube?
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Tip of the nose, to the ear lobe and then to the xiphoid process
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Can you strip or milk a pleural chest tube?
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No, may damage lung tissue by entrapment
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What do you do when you see the flash in IV insertion?
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Go in a little further and then push the hub off.
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The nurse prepares to administer an enteral feeding to a client through a nasogastric tube. Which is the priority intervention for the nurse to complete before administering the feeding?
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Determine tube placement.
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When suctioning the tracheostomy airway the nurse would do all of these except:
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Hyperoxygenate the client
Continuously monitor respirations and BP Pull back 1-2 cm after meeting resistance Make no more than 3 passes with the suction catheter in one sitting. |
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The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
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The system has an air leak.
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The nurse is care for a client receiving antacids via NG tube every 4 hours. There is an order to check the gastric pH every 4 hours. Which of the following responses is true regarding the gastric pH?
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It should be between 3-5.
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What should a suitable vein for venipuncture feel like?
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Round, firm, elastic, and engorged
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Name 3 factors to consider when choosing an appropriate vein for venipuncture?
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* the patient's medical history
* his age, size, general condition, and level of physical activity * the condition of his veins * the type of I.V. fluid or medication to be infused * the expected duration of I.V. therapy * your skill at venipuncture. |
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The nurse is preparing to initiate IV therapy for a client who is to receive several blood transfusions. Which venipuncture site would the nurse choose?
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Cephalic vein
Rationale- it can accept a large bore catheter. |
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The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:
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Place the tube in a bottle of sterile water.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action. |
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The nurse is instructing the unlicensed assistant on how to care for a client with chest tubes that are connected to water seal drainage. Which of the following instruction would be appropriate for the nurse to give the unlicensed assistant?
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Mark the time and amount of drainage collected in the container.
It is appropriate for an unlicensed assistant to mark the time of measurement and fluid level in the collection container. |
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The nurse is caring for a client after a lung lobectomy. The nurse notes fluctuating water levels in the water-seal chamber of the client's chest tube. What action should the nurse take?
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Do nothing, but continue to monitor the client.
Fluctuation in the water-seal chamber is a normal finding that occurs as the client breathes. No action is required except for continued monitoring of the client. The nurse doesn't need to notify the physician. Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, such as from a loose connection in the chest tube tubing. The water-seal chamber should be filled initially to the 2 cm line, and no more water should be added. |
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The nurse is assessing a client 24 hours following a cholecystectomy. The nurse noted that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate?
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Document the findings.
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