NUR 400 Final Exam QUESTIONS AND
CORRECT ANSWERS
Dysphagia - CORRECT ANSWER inability to swallow or difficulty in swallowing
2 key points about Dysphagia - CORRECT ANSWER 1. 30 mins prior to meal time, the pt
needs to be sitting at 90 degree unless its contraindicated
2. Monitor for possibility of aspiration
-s/s of aspiration
-Coughing
-Wheezing
-Redness of face
-Decrease O2 sat
2 key points about Nasogastric Tube - CORRECT ANSWER Used for pt who suffers from
dysphagia (difficulty swallowing)
Residual volume must always be checked q4h d/t risk for aspiration *** if there is a large amount of
residual volume, that means pt is not digesting the food - inform MD**
Nasogastric Tube Supplies - CORRECT ANSWER Nasogastric tube
Irrigation tray - 60 ml syringe
A bottle of sterile water
lubricant
NGT insertion - CORRECT ANSWER 1. Measure the tube from the nose to the back of the ear
and down a little pass the bottom of the xiphoid process
,2. Mark the tube (sharpie)
3. Have the patient swallow while inserting the tube (with or without ice chips)
NGT placement - CORRECT ANSWER 1. Once the NGT is inserted, aspirate 30 mL of air
2. Place the stethoscope over the stomach and listen to the "wooooosh" sound as you inject the air
3. If necessary, get an order for x ray for proper placement.
NGT medication administration - CORRECT ANSWER 1. Check if pt is on any fluid
restrictions
2. Check gastric residual and put it back after.
3. Make sure to kink the tube so that air won't go in the tube (air causes bloating)
4. Crush medication and mix with water until diluted and poured in the syringe. [except enteric coated
or with granules (Protonix)]
5. Flush 5-10 mL in between medications
6. Flush 30 mL after all medication has been administered
NGT removal - CORRECT ANSWER 1. Needs a doctor's order
2. Flush with 10 mL water/NS or 30-50 mL of air
3. Have pt take a deep breath while removing the tube quickly
,7 Rules about Body mechanics - CORRECT ANSWER -Always bend the knee and have a
wide base for support
-Always point your toes to the direction you're going
-When transferring a patient to a chair or wheelchair, have them hold on to your shoulders and have
your dominant foot in between their legs.
-Always count (1-2-3) out loud and tell them how to position or move
themselves.
a. If the patient is weaker on one side, have them put their weight on the stronger side before standing
up.
b. Turn your entire body rather than pivoting to avoid hurting your back
-When re positioning the patient, you has always make sure to avoid hurting your wrists
-Make sure the bed is at your hip level.
-If the patient is too heavy, ask for help.
How do we measure syringe gauge sizes? - CORRECT ANSWER THE SMALLER THE
NUMBER, THE BIGGER THE DIAMETER (GAUGE) OF NEEDLE
IV site inspection - CORRECT ANSWER look atthe IV catheter insertion site for redness,
swelling, or bruising. Redness can indicate irritation, inflammation, infection, or thrombus formation.
... Assess the condition of the transparent catheter dressing. The dressing should be clean, dry, and
adhere securely to the skin around the IV catheter insertion site
Intravenous sites - CORRECT ANSWER -Common sites:
Dorsal area of the hands
Forearm
, -Antecubital Fossa
Uncommon sites
Dorsal area of feet (needs an order)
Cephalic (infants)
Intravenous syringe length - CORRECT ANSWER Neonate and Infants:
19 mm (<1 inch)
Child and Older Adult:
1 inch
Adults:
1-1 ¼ inches
Intravenous guages - CORRECT ANSWER Neonate and Infants:
24-26 G
Child and Older Adults:
22 G
Adults:
18, 20, and 22 G
Intravenous angle - CORRECT ANSWER *** Angle depends upon where the IV insertion site
is.
(8) Rights of administration - CORRECT ANSWER 1. Right Patient
2. Right Medication
3. Right Dose
4. Right Route
5. Right Time
CORRECT ANSWERS
Dysphagia - CORRECT ANSWER inability to swallow or difficulty in swallowing
2 key points about Dysphagia - CORRECT ANSWER 1. 30 mins prior to meal time, the pt
needs to be sitting at 90 degree unless its contraindicated
2. Monitor for possibility of aspiration
-s/s of aspiration
-Coughing
-Wheezing
-Redness of face
-Decrease O2 sat
2 key points about Nasogastric Tube - CORRECT ANSWER Used for pt who suffers from
dysphagia (difficulty swallowing)
Residual volume must always be checked q4h d/t risk for aspiration *** if there is a large amount of
residual volume, that means pt is not digesting the food - inform MD**
Nasogastric Tube Supplies - CORRECT ANSWER Nasogastric tube
Irrigation tray - 60 ml syringe
A bottle of sterile water
lubricant
NGT insertion - CORRECT ANSWER 1. Measure the tube from the nose to the back of the ear
and down a little pass the bottom of the xiphoid process
,2. Mark the tube (sharpie)
3. Have the patient swallow while inserting the tube (with or without ice chips)
NGT placement - CORRECT ANSWER 1. Once the NGT is inserted, aspirate 30 mL of air
2. Place the stethoscope over the stomach and listen to the "wooooosh" sound as you inject the air
3. If necessary, get an order for x ray for proper placement.
NGT medication administration - CORRECT ANSWER 1. Check if pt is on any fluid
restrictions
2. Check gastric residual and put it back after.
3. Make sure to kink the tube so that air won't go in the tube (air causes bloating)
4. Crush medication and mix with water until diluted and poured in the syringe. [except enteric coated
or with granules (Protonix)]
5. Flush 5-10 mL in between medications
6. Flush 30 mL after all medication has been administered
NGT removal - CORRECT ANSWER 1. Needs a doctor's order
2. Flush with 10 mL water/NS or 30-50 mL of air
3. Have pt take a deep breath while removing the tube quickly
,7 Rules about Body mechanics - CORRECT ANSWER -Always bend the knee and have a
wide base for support
-Always point your toes to the direction you're going
-When transferring a patient to a chair or wheelchair, have them hold on to your shoulders and have
your dominant foot in between their legs.
-Always count (1-2-3) out loud and tell them how to position or move
themselves.
a. If the patient is weaker on one side, have them put their weight on the stronger side before standing
up.
b. Turn your entire body rather than pivoting to avoid hurting your back
-When re positioning the patient, you has always make sure to avoid hurting your wrists
-Make sure the bed is at your hip level.
-If the patient is too heavy, ask for help.
How do we measure syringe gauge sizes? - CORRECT ANSWER THE SMALLER THE
NUMBER, THE BIGGER THE DIAMETER (GAUGE) OF NEEDLE
IV site inspection - CORRECT ANSWER look atthe IV catheter insertion site for redness,
swelling, or bruising. Redness can indicate irritation, inflammation, infection, or thrombus formation.
... Assess the condition of the transparent catheter dressing. The dressing should be clean, dry, and
adhere securely to the skin around the IV catheter insertion site
Intravenous sites - CORRECT ANSWER -Common sites:
Dorsal area of the hands
Forearm
, -Antecubital Fossa
Uncommon sites
Dorsal area of feet (needs an order)
Cephalic (infants)
Intravenous syringe length - CORRECT ANSWER Neonate and Infants:
19 mm (<1 inch)
Child and Older Adult:
1 inch
Adults:
1-1 ¼ inches
Intravenous guages - CORRECT ANSWER Neonate and Infants:
24-26 G
Child and Older Adults:
22 G
Adults:
18, 20, and 22 G
Intravenous angle - CORRECT ANSWER *** Angle depends upon where the IV insertion site
is.
(8) Rights of administration - CORRECT ANSWER 1. Right Patient
2. Right Medication
3. Right Dose
4. Right Route
5. Right Time
