A nurse has just completed the insertion of a nasogastric (NG) tube. Click to specify whether each potential nursing action is indicated or contraindicated.
Flush the NG with 60 mL of water
Obtain the ordered chest x-ray for placement verification
Aspirate a sample of gastrointestinal (GI) conte...
Nursing Skills Exam Questions and
Answers
A nurse has just completed the insertion of a nasogastric (NG) tube. Click to specify
whether each potential nursing action is indicated or contraindicated.
Flush the NG with 60 mL of water
Obtain the ordered chest x-ray for placement verification
Aspirate a sample of gastrointestinal (GI) contents
Begin ordered feeding through the tube - Answer-Indicated:
-Obtain the ordered chest x-ray for placement verification
-Aspirate a sample of GI contents
Contraindicated:
-Flush the NG with 60 mL of water
-Begin ordered feeding through the tube
The nurse is administering the first dose of the client's prescribed ceftriaxone 1 gram
intravenously (IV) in 100mL of normal saline over 60 minutes. Drag the assessment
findings that require follow-up during the first 10-15 minutes of administration to the
boxes on the right.
IV infusion rate 50 mL/hr
Client appears flushed
Client requests to ambulate
Client complains of itching
Client is wheezing - Answer--Client appears flushed
-Client complains of itching
-Client is wheezing
The nurse is performing tracheostomy suctioning on a client. When inserting the suction
catheter, the nurse meets resistance and notes that the client begins to cough. The
client's pulse oximetry reading is 97% on room air, skin color pink, and RR 22.
Arrange the nursing actions in the order they should be performed.
Gently rotate the suction catheter while withdrawing
Re-apply the client's tracheostomy mask
Apply intermittent suction
Pull the suction catheter back ½ inch - Answer-1. Pull suction catheter back 1/2 inch
2. Apply intermittent suction
3. Gently rotate the suction catheter while withdrawing
4. Re-apply the client's tracheostomy mask
The nurse on a medical-surgical floor received a report on the client group and reviews
the electronic health records. For each client, highlight the assessment findings that
would indicate the need for the client to have sequential compression devices applied. -
Answer-Joan Miller -->
Daniel Alvarado -->
-Motor vehicle accident (MVA) 1 day ago
-Bedrest with bathroom privileges
Harold Zimmerman -->
-70-year-old
-Prostate cancer
The nurse is caring for a client with a newly placed percutaneous endoscopic
gastrostomy (PEG) tube and is preparing to administer the next scheduled feeding via
feeding tube pump. Highlight the findings that require follow-up by the nurse. - Answer--
Client reporting nausea
-distention
-210 mL of residual
-Client resting in prone position
The nurse has an order to obtain a urine specimen from the client's indwelling catheter.
Order the steps in the correct sequence.
Transport the urine specimen to the laboratory
Withdraw the appropriate amount of urine
Unclamp catheter tubing
Attach a syringe to the collection port of the indwelling catheter
Wipe the specimen port of the catheter with antiseptic
Clamp catheter tubing below collection port
Transfer the urine to a sterile specimen container - Answer-1. Clamp catheter tubing
below collection port
2. Wipe the specimen port of the catheter with antiseptic
3. Attach a syringe to the collection port of the indwelling catheter
4. Withdraw the appropriate amount of urine
5. Transfer the urine to a sterile specimen container
6. Unclamp catheter tubing
7. Transport the urine specimen to the laboratory
A nurse asks the unlicensed assistive personnel (UAP) to do each of the following tasks
after removal of the indwelling catheter. Which statements illustrate appropriate
delegation by the nurse? Select all that apply.
"Report to me the time and amount the client voids for the first time after removal."
"If the client cannot void, reinsert the indwelling urinary catheter."
"Assess the client for bladder distension before the end of your shift."
"Explain to the client to let you know if the first time they void is uncomfortable."
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