Nursing 221 Exam 2: Skills/Clinical
Accurate 100%
Fluid from a tube properly placed in the stomach should test at a pH of ___ or lower -
ANSWER 5
Anything higher means that the tube MUST be replaced
To determine where to mark the correct length on an NG tube for a 2-month-old infant,
how should the nurse measure? - ANSWER From nose to earlobe, then from earlobe
to midpoint between xiphoid process and umbilicus
During a teaching session, the nurse informs the child's family that placement of a
postpyloric tube is most reliably confirmed by which method? - ANSWER A radiograph
of the abdomen
The nurse is attempting to insert an NG tube into a 13-year-old child with no cervical
injuries. To facilitate passage of the NG tube with minimal trauma, what should the
nurse do? - ANSWER flex the child's head forward
When educating the family of a child with an NG tube, how should the nurse describe
the purpose of a gastric decompression tube? - ANSWER it ensures that the child's
stomach remains empty
During assessment of a child with an orogastric tube for gastric decompression in place,
the nurse observes dry and irritated oral mucous membranes. How should the nurse
proceed? - ANSWER provide more frequent oral care
An incentive spirometer after surgery is normally used for? - ANSWER it prevents post-
operative complications
A 6-month-old infant has an NG tube in place after surgery. The infant no longer needs
the tube. Before removing the tube, what must the nurse do? - ANSWER Occlude the
tube by bending it
(this is so that no secretions from the stomach end up in the lungs)
The nurse is assessing a 9-month-old infant who is receiving enteral nutrition through
an NG tube. During assessment, the infant coughs and vomits a small amount of thick
fluid. What should the nurse do next? - ANSWER Suction the oropharynx
Which statement demonstrates the patient's ability to perform incentive spirometry
correctly? - ANSWER The patient inhales slowly and deeply from a normal expiratory
breath.
, What is the minimum acceptable postoperative volume to be achieved with an incentive
spirometer? - ANSWER 2000ml
A patient with COPD is recovering from postoperative abdominal surgery. The
prescribing practitioner has ordered an incentive spirometer to decrease the chance of
pneumonia. Which outcome is an unexpected outcome? - ANSWER Shortness of
breath after the use of the incentive spirometer
what position should you place a patient when caring for Gastrostomy Tube,
Jejunostomy Tube, and Gastrojejunostomy Tubes - ANSWER semi-fowler position with
knee's bent
this helps relax the abdominal muscles
when should you flush the extension tubing of a Gastrostomy Tube, Jejunostomy Tube,
or Gastrojejunostomy Tube? - ANSWER before and after formula and medication
adminsteration
How should you flush a gastrostomy tube? - ANSWER flush with the lowest volume of
water necessary.
typically 2-5 milliliters for children and 1 milliliter or less for neonates
How should you flush a GJT? - ANSWER flush the jejuno port every 4 hours with the
lowest volume needed to clear the tube
and flush the gastric port after use
You should vent a gastric port when ________ or as needed - ANSWER ordered
What does granulation tissue formation around the GT stoma site indicate? - ANSWER
Excess tissue has no sensation. (this is a normal occurrence)
A child has a GT in place. During daily care, leakage of stomach contents is observed
around the GT; however, the child is tolerating the procedure and does not appear to be
in pain. What might the leakage indicate? - ANSWER balloon deflation
A nurse is giving the family of a child with a new GT discharge instructions. Which
statement by the family indicates that they understand the purpose of flushing the GT
before and after medication administration? - ANSWER "flushing prevents clogging"
A child is admitted to the pediatric inpatient unit following a GT placement. The mother
asks what the best way is to cleanse the tube site. What should the nurse use to
cleanse the site? - ANSWER Soap and water
Accurate 100%
Fluid from a tube properly placed in the stomach should test at a pH of ___ or lower -
ANSWER 5
Anything higher means that the tube MUST be replaced
To determine where to mark the correct length on an NG tube for a 2-month-old infant,
how should the nurse measure? - ANSWER From nose to earlobe, then from earlobe
to midpoint between xiphoid process and umbilicus
During a teaching session, the nurse informs the child's family that placement of a
postpyloric tube is most reliably confirmed by which method? - ANSWER A radiograph
of the abdomen
The nurse is attempting to insert an NG tube into a 13-year-old child with no cervical
injuries. To facilitate passage of the NG tube with minimal trauma, what should the
nurse do? - ANSWER flex the child's head forward
When educating the family of a child with an NG tube, how should the nurse describe
the purpose of a gastric decompression tube? - ANSWER it ensures that the child's
stomach remains empty
During assessment of a child with an orogastric tube for gastric decompression in place,
the nurse observes dry and irritated oral mucous membranes. How should the nurse
proceed? - ANSWER provide more frequent oral care
An incentive spirometer after surgery is normally used for? - ANSWER it prevents post-
operative complications
A 6-month-old infant has an NG tube in place after surgery. The infant no longer needs
the tube. Before removing the tube, what must the nurse do? - ANSWER Occlude the
tube by bending it
(this is so that no secretions from the stomach end up in the lungs)
The nurse is assessing a 9-month-old infant who is receiving enteral nutrition through
an NG tube. During assessment, the infant coughs and vomits a small amount of thick
fluid. What should the nurse do next? - ANSWER Suction the oropharynx
Which statement demonstrates the patient's ability to perform incentive spirometry
correctly? - ANSWER The patient inhales slowly and deeply from a normal expiratory
breath.
, What is the minimum acceptable postoperative volume to be achieved with an incentive
spirometer? - ANSWER 2000ml
A patient with COPD is recovering from postoperative abdominal surgery. The
prescribing practitioner has ordered an incentive spirometer to decrease the chance of
pneumonia. Which outcome is an unexpected outcome? - ANSWER Shortness of
breath after the use of the incentive spirometer
what position should you place a patient when caring for Gastrostomy Tube,
Jejunostomy Tube, and Gastrojejunostomy Tubes - ANSWER semi-fowler position with
knee's bent
this helps relax the abdominal muscles
when should you flush the extension tubing of a Gastrostomy Tube, Jejunostomy Tube,
or Gastrojejunostomy Tube? - ANSWER before and after formula and medication
adminsteration
How should you flush a gastrostomy tube? - ANSWER flush with the lowest volume of
water necessary.
typically 2-5 milliliters for children and 1 milliliter or less for neonates
How should you flush a GJT? - ANSWER flush the jejuno port every 4 hours with the
lowest volume needed to clear the tube
and flush the gastric port after use
You should vent a gastric port when ________ or as needed - ANSWER ordered
What does granulation tissue formation around the GT stoma site indicate? - ANSWER
Excess tissue has no sensation. (this is a normal occurrence)
A child has a GT in place. During daily care, leakage of stomach contents is observed
around the GT; however, the child is tolerating the procedure and does not appear to be
in pain. What might the leakage indicate? - ANSWER balloon deflation
A nurse is giving the family of a child with a new GT discharge instructions. Which
statement by the family indicates that they understand the purpose of flushing the GT
before and after medication administration? - ANSWER "flushing prevents clogging"
A child is admitted to the pediatric inpatient unit following a GT placement. The mother
asks what the best way is to cleanse the tube site. What should the nurse use to
cleanse the site? - ANSWER Soap and water
