NUR 222

NUR 222 Exam with 100% correct answers Indications for NG tube - Correct Answer-1. Nutrition 2. decompress or drain unwanted fluid and air from the stomach 3. monitor bleeding in the GI tract 4. remove substances 5. treat intestinal obstruction 6. give meds, gastric lavage assessments prior to insertion of NG tube - Correct Answer-1. assess patency of nares 2. auscultate for bowel sounds 3. inspect abdomen for distention or firmness if the abdomen is distended consider measuring the abdominal girth at the - Correct Answer-umbilicus to establish a baseline NG tube insertion - Correct Answer-- Assess abdomen, nares patency, facial trauma, nasal blockages -Position: Fowler to high-fowler - Clean gloves -Measure tube: Nostril to tip of earlobe to tip of xiphoid process -Lubricate tip and gently insert tube directing up and backward -When pharynx is reached, instruct patient to touch chin to chest -Advance tube while encouraging the patient to sip water or swallow -Stop when patient breathes -Advance until marking is reached -Secure tube (do not let go of tube) - Measure external length of tube - Verify placement Verification of placement - Correct Answer-x-ray pH levels pH level of gastric contents - Correct Answer-<5.5 pH if patient is taking acid inhibiting medication - Correct Answer-4-6 intestinal fluid pH - Correct Answer-7 or higher respiratory fluid pH - Correct Answer-6 or higher NG tube documentation - Correct Answer-- size and placement - location of tube - measurement of exposed tube - patients response to procedure - method of confirmation Care of Salem sump tube - Correct Answer--Attach to INTERMITTENT suction if ordered -Irrigate per policy -Document irrigation and drainage -Pause suction to listen to bowel sounds -May administer medications if ordered; Hold suction for 30-60 minutes after -Secure vent above level of stomach to prevent gastric contents from leaking and clogging air vent types of feeding tubes - Correct Answer-- short term - long term - risk for aspiration - digestive problems types of tube feeding - Correct Answer-- jevity - glucema - nepro - two cal - pulmocare site care for G tube/J tube - Correct Answer-- Monitor site every shift - Monitor sutures if present (common finding if newly placed) - Cleanse site daily with NS or soap and water (per order or agency protocol) - Ensure area is dry after cleaning - Rotate bumper daily - Leave open to air, if drainage is present, apply precut gauze under bumper measure residual volume every (enteral feeding key assessments) - Correct Answer-4-6 hours blood glucose every (enteral feeding key assessments) - Correct Answer-6 hours enteral feeding key assessments - Correct Answer-- Measure residual volume every 4-6 hours or per agency protocol - Blood Glucose every 6 hours or per agency protocol - Measure and record I & O - Weight patient - Labs - Respiratory status (Signs of aspiration?) and comfort level - GI assessment (bowel sounds, distention, diarrhea, nausea, vomiting) - Tube insertion site for skin impairment enteral feeding medication administration - Correct Answer-- pause tube feeding - high fowlers - 10 rights - gloves - clamp - heck placement and residual - select part - insert syringe - 5-10ml between medication - flush tube 30-60ml - one med at a time - flush with water - resume tube feeding tube feeding must contain - Correct Answer-1. formula 2. feeding schedule or rate 3. water flush volume and frequency 4. residual check 5. some facilities have you insert 30 ml of air into NG and pull back 5-10 ml for each pH testing continuous feeding what is needed and how is It schedules - Correct Answer-an external feeding pump is needed to regulate the flow of formula may be scheduled at night or around the clock intermittent feedings - Correct Answer-delivered at regular intervals delivered by gravity (bolus) delivered by a feeding pump over a set period of time enteral feeding procedure: Via pump or bolus - Correct Answer-- Elevate HOB 30-45 degrees - Gloves - Verify tube placement - Measure gastric residual (amount of feeding remaining in the stomach) - >200-250ml associated with high risk for aspiration - Hold feeding per agency protocol for high residuals Return gastric residual (return volume per agency protocol) prepare formula/ feeding bag - Correct Answer-- Check expiration date of the formula - Clean top of feeding container with disinfectant before opening - Pour formula into feeding bag or spike closed system and prime tubing - Hang bag on IV pole and adjust to 12-inch above stomach - Label bag and tubing with date and time administering formula - Correct Answer-- Attach tubing to feeding tube - Administer at prescribed rate - Irrigate feeding tube with 30-60ml of water after intermittent feeds or as ordered - Clamp tubing promptly after feeds before air enters patient should remain in high fowlers for at least how long after feeding - Correct Answer-1 hour bolus procedure - Correct Answer-- Prepare formula (same as preparing for pump administration) - Administer formula - Attach syringe to feeding tube - Regulate rate by adjusting the height of the syringe - Irrigate feeding tube with 30-60ml of water after intermittent feeds or as ordered - Clamp tubing promptly after feeds before air enters clogged feeding tube: nursing actions - Correct Answer-flush with 30-60 ml water after use or every 4 hours crush medications and mix with water and flush after administration nausea and vomiting nursing actions - Correct Answer-ensure HOB elevated administer antiemetic as ordered hold feeding tube and notify aspirate for gastric residual for cramping and nausea provider may decrease administration rate gastric residual exceeds 200 ml nursing actions - Correct Answer-assessment notify HOB elevated reassess residual 3 or more diarrhea episodes in 24 hours nursing actions - Correct Answer-notify confer w provider to modify type of formula, concentration or rate of infusion consider other causes determine is pt is receiving antibiotics or meds (containing sorbitol) will induce diarrhea skin care to maintain integrity Peripheral IV lines are used for patients who need - Correct Answer-- fluid and electrolyte replacement because they cannot take it by mouth - medication administration - blood administration supplies needed for IV insertion - Correct Answer-- 2 IV catheters - no more than 2 attempts - gloves - tourniquet - antiseptic swab - gauze - j loop/saline lock - 10 mL prefilled saline syringe - transparent dressing and tape - IV tubing and fluids as ordered IV insertion preparation - Correct Answer-- educate patient - find site (point IV towards the heart) - prime j-loop to remove air - prepare supplies - pain prevention IV insertion site: adults - Correct Answer-- hand or inner arm - non dominant arm - use most distal site first IV insertion site: babies - Correct Answer-scalp and feet Avoid insertion of IVs under these circumstances - Correct Answer-- same side as mastectomy - extremity with vascular dialysis fistulas - extremities with infection, infiltration, burn injury - antecubital - inside of wrist IV insertion steps: - Correct Answer-1. clean skin 2. apply tourniquet 3. stabilize vessel and insert needle. Bevel up 10-15 degrees 4. advance catheter 5. remove tourniquet 6. stabilize catheter 7. remove needle 8. connect Jloop 9. flush 10. secure with dressing how to label the securing site of IV - Correct Answer-date, time, initials documentation of IV insertion - Correct Answer-- date and time of insertion - size of catheter - location and condition of the IV site - number of insertion attempts - patient tolerance of IV insertion - pertinent patient teaching how often do you change site of IV insertion - Correct Answer-per site policy - usually every 72-96 hours If fluid does not flow easily into the vein what do you do - Correct Answer-- check connections - check that clamp is open - check that there are no kinks in the line - check that arm is not bent - may be against a valve Inadvertently accessing an artery - Correct Answer-- flushing will result in white appearance - blood return may pulsate - patient may report numbness/tingling - remove, hold pressure at site, notify healthcare provider What is IV infiltration - Correct Answer-- skin around IV is edematous or cool to touch - fluid is leaking into tissues - remove and restart what is phlebitis - Correct Answer-- inflammation of a vein - redness, swelling, heat, pain at the site - caused by chemical irritation or mechanical trauma what is a blown vein - Correct Answer-blood leaking into tissues through a hole in the vessel wall Gravity Administration - Correct Answer-drip rate - volume/time converted to ggt discontinuing an IV - Correct Answer-- remove tape around site - place 2x2 gauze over the insertion site - gently remove catheter - apply pressure to site for: - 2-3 minutes for general patients - 5-10 minutes for patients on anticoagulant therapy (asa, Coumadin) 0