NUR 331 Exam 3 Questions And Answers
Reasons a patient may have an NG tube (3)
1. decompression: remove fluid and air/gas via gravity or suction
2. administer feedings, medications, and contrast
3. compress bleeding sites until endoscopy
Contraindications for NG tube insertion include: (3)
1. facial trauma or recent brain surgery
2. recent nasal surgery, & known polyps, or deviated septum
3. esophageal varicies with recent or current perforation, banding, or cautery
Before the placement of the tube in the patient, the nurse should check: (5)
1. The patency of the nares & presence of irritated mucosa
2. Adequate swallowing: Good for identifying those patients that will be at risk for
aspiration
3. The suctioning if it is working properly bedside & other available supplies like
stethoscope & tape
4. Lung & bowel sounds
5. Provider order with clarification of suction to be used like continuous or
low-intermittent
Confirming placement: EBP = evidence-based practice (2)
1. EBP for confirming tube placement is done by completing a x-ray (KUB)
2. Aspirating fluid to test for stomach pH
Post-placement: (3)
1. secure tube to patient's gown (usually tape and safety pin)
,2. watch for skin breakdown and dry mucous membranes
3. provide frequent oral care (improves patient comfort & decreases infection
FiO2
fraction of inspired oxygen, an approximation of the oxygen a patient inspires
Oral care frequency: (2)
1. Every 2 hours and PRN. Use suction, swabs, and chlorhexidine rinses if ordered.
2. At least once a shift, consider before or after meals.
What are some reasons a patient may need assistance with feeding? (5)
1. Risk for aspiration
2. Decreased cough or gag reflexes
3. Altered level of consciousness: ex. patients easily distracted and need reminders to
swallow
4. Motor deficits: ex. weak hand grip post stroke
5. Visual impairments ex. guide with hands or orienting food on a plate by a clock face
Barriers to nutrition intake for those with dysphagia (difficulty swallowing) 5
1. Diet requires a consistency modification that is not appealing, such as vegetables or
meat pureed (it's gross - google it)
2. Easily fatigued since it is very labour intensive to swallow and chew effectively
3. Frustrated due to above or due to reduction in independence-cannot eat the foods
they like or snack when they want
4. There are disease processes that can affect a patient's taste- ex. Covid or CVA
(stroke)
5. Can be difficult to make considerations for culture or diet preferences/needs. ex.
kosher or vegetarian
,The nurse and RT need to ensure the oxygen is delivered with the proper:(2)
equipment & flow-rate
Oxygen must have an ___ from the Provider
order
The flow meter connects to the oxygen outlet and _____ the amount delivered (L/min)
regulates
cyanosis
cyanosis (bluish discoloration due to circulatory or oxygenation problems)
metabolic acidosis
responsible acid accumulation in the body
Safety considerations in oxygen administration include: (3)
fire, equipment failure, & pressure risk
clubbing-fingers & toes
elengthening of the fingertips and toes due to prolonged deficiency in oxygen
right-sided heart failure
a disorder that shows less effective pumping in the right side of the heart
respiratory acidosis
A decrease in blood pH as a result of hypoventilation (not breathing enough) and the
accumulation of Co2.
Nasal Cannula
a device to deliver oxygen; two prongs of device are placed into the patient nostrils
The nurse should assess the client's skin for breakdown and ___ for irritation.
mucous membranes
Simple Face Mask and who?
, mask has vents; oxygen may be delivered at 5-10 L/min (40-60% FiO2)
- post-anesthesia or post intubation
Nonrebreather Mask and who?
mask with a valve that closes during expiration and reservoir bag that inflates with high
concentrations of oxygen; 10-15 L/min (80-95%)
- carbon dioxide poisoning, smoke inhalation, critically ill patients
Venturi Mask
delivers a predetermined and fixed oxygen concentration to the client.
Early signs & symptoms of hypoxia include: (6)
restlessness, confusion, anxiety, elevated blood pressure, ↑HR & RR, and dyspnea
incentive spirometry (IS)
a breathing exercise to improve lung function
Late signs & symptoms of hypoxia include: (6)
cyanosis metabolic acidosis bradycardia hypotension ↓ activity & level of consciousness
Decompression
Removing fluid & air/gas via gravity or suction
Chronic signs & symptoms of hypoxia include: (5)
clubbing (fingers & toes)
edema
right-sided heart failure
respiratory acidosis
Reasons a patient may have an NG tube (3)
1. decompression: remove fluid and air/gas via gravity or suction
2. administer feedings, medications, and contrast
3. compress bleeding sites until endoscopy
Contraindications for NG tube insertion include: (3)
1. facial trauma or recent brain surgery
2. recent nasal surgery, & known polyps, or deviated septum
3. esophageal varicies with recent or current perforation, banding, or cautery
Before the placement of the tube in the patient, the nurse should check: (5)
1. The patency of the nares & presence of irritated mucosa
2. Adequate swallowing: Good for identifying those patients that will be at risk for
aspiration
3. The suctioning if it is working properly bedside & other available supplies like
stethoscope & tape
4. Lung & bowel sounds
5. Provider order with clarification of suction to be used like continuous or
low-intermittent
Confirming placement: EBP = evidence-based practice (2)
1. EBP for confirming tube placement is done by completing a x-ray (KUB)
2. Aspirating fluid to test for stomach pH
Post-placement: (3)
1. secure tube to patient's gown (usually tape and safety pin)
,2. watch for skin breakdown and dry mucous membranes
3. provide frequent oral care (improves patient comfort & decreases infection
FiO2
fraction of inspired oxygen, an approximation of the oxygen a patient inspires
Oral care frequency: (2)
1. Every 2 hours and PRN. Use suction, swabs, and chlorhexidine rinses if ordered.
2. At least once a shift, consider before or after meals.
What are some reasons a patient may need assistance with feeding? (5)
1. Risk for aspiration
2. Decreased cough or gag reflexes
3. Altered level of consciousness: ex. patients easily distracted and need reminders to
swallow
4. Motor deficits: ex. weak hand grip post stroke
5. Visual impairments ex. guide with hands or orienting food on a plate by a clock face
Barriers to nutrition intake for those with dysphagia (difficulty swallowing) 5
1. Diet requires a consistency modification that is not appealing, such as vegetables or
meat pureed (it's gross - google it)
2. Easily fatigued since it is very labour intensive to swallow and chew effectively
3. Frustrated due to above or due to reduction in independence-cannot eat the foods
they like or snack when they want
4. There are disease processes that can affect a patient's taste- ex. Covid or CVA
(stroke)
5. Can be difficult to make considerations for culture or diet preferences/needs. ex.
kosher or vegetarian
,The nurse and RT need to ensure the oxygen is delivered with the proper:(2)
equipment & flow-rate
Oxygen must have an ___ from the Provider
order
The flow meter connects to the oxygen outlet and _____ the amount delivered (L/min)
regulates
cyanosis
cyanosis (bluish discoloration due to circulatory or oxygenation problems)
metabolic acidosis
responsible acid accumulation in the body
Safety considerations in oxygen administration include: (3)
fire, equipment failure, & pressure risk
clubbing-fingers & toes
elengthening of the fingertips and toes due to prolonged deficiency in oxygen
right-sided heart failure
a disorder that shows less effective pumping in the right side of the heart
respiratory acidosis
A decrease in blood pH as a result of hypoventilation (not breathing enough) and the
accumulation of Co2.
Nasal Cannula
a device to deliver oxygen; two prongs of device are placed into the patient nostrils
The nurse should assess the client's skin for breakdown and ___ for irritation.
mucous membranes
Simple Face Mask and who?
, mask has vents; oxygen may be delivered at 5-10 L/min (40-60% FiO2)
- post-anesthesia or post intubation
Nonrebreather Mask and who?
mask with a valve that closes during expiration and reservoir bag that inflates with high
concentrations of oxygen; 10-15 L/min (80-95%)
- carbon dioxide poisoning, smoke inhalation, critically ill patients
Venturi Mask
delivers a predetermined and fixed oxygen concentration to the client.
Early signs & symptoms of hypoxia include: (6)
restlessness, confusion, anxiety, elevated blood pressure, ↑HR & RR, and dyspnea
incentive spirometry (IS)
a breathing exercise to improve lung function
Late signs & symptoms of hypoxia include: (6)
cyanosis metabolic acidosis bradycardia hypotension ↓ activity & level of consciousness
Decompression
Removing fluid & air/gas via gravity or suction
Chronic signs & symptoms of hypoxia include: (5)
clubbing (fingers & toes)
edema
right-sided heart failure
respiratory acidosis
